Provider Demographics
NPI:1053948562
Name:BARNSTABLE, ELLEN GRACE (MD)
Entity type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:GRACE
Last Name:BARNSTABLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:ELLEN
Other - Middle Name:GRACE
Other - Last Name:WRIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:146 E GENEVA SQ
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-9695
Mailing Address - Country:US
Mailing Address - Phone:622-249-5000
Mailing Address - Fax:
Practice Address - Street 1:146 E GENEVA SQ
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-9695
Practice Address - Country:US
Practice Address - Phone:622-249-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11021938A390200000X
390200000X
WI83862-20207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100287398Medicaid