Provider Demographics
NPI:1699728436
Name:ELLWOOD, JUDITH (MS, APRN)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:ELLWOOD
Suffix:
Gender:F
Credentials:MS, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 ALLEN ST
Mailing Address - Street 2:STE 403
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4570
Mailing Address - Country:US
Mailing Address - Phone:802-772-4414
Mailing Address - Fax:802-772-7973
Practice Address - Street 1:275 ROUTE 30 N
Practice Address - Street 2:
Practice Address - City:BOMOSEEN
Practice Address - State:VT
Practice Address - Zip Code:05732-9647
Practice Address - Country:US
Practice Address - Phone:802-468-5641
Practice Address - Fax:802-468-2923
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT1010013650363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02780087Medicaid
VT1012833Medicaid
NP550902Medicare PIN
NP550904Medicare PIN