Provider Demographics
NPI:1053092585
Name:GALVANIN-ELLSWORTH, ELISE
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:GALVANIN-ELLSWORTH
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 1:149 GRANVILLE DRIVE
Mailing Address - Street 2:OTIS AIR NATIONAL GUARD BASE
Mailing Address - City:BUZZARDS BAY
Mailing Address - State:MA
Mailing Address - Zip Code:02542-1808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:149 GRANVILLE DRIVE
Practice Address - Street 2:OTIS AIR NATIONAL GUARD BASE
Practice Address - City:BUZZARDS BAY
Practice Address - State:MA
Practice Address - Zip Code:02542
Practice Address - Country:US
Practice Address - Phone:508-968-4091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2287535363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily