Provider Demographics
NPI:1962723932
Name:ANDREW, ELLEN
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:ANDREW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 ELK CT
Mailing Address - Street 2:
Mailing Address - City:DIVIDE
Mailing Address - State:CO
Mailing Address - Zip Code:80814-7776
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 ELK CT
Practice Address - Street 2:
Practice Address - City:DIVIDE
Practice Address - State:CO
Practice Address - Zip Code:80814-7776
Practice Address - Country:US
Practice Address - Phone:719-686-1779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-14
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5526174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist