MEDICARE: MS. ARDYTHE K ELLISON RN, MSN, CNM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	176B00000X	Midwife	36610	WV

General Provider Information

NPI Number	:	1902955131
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ARDYTHE K ELLISON RN, MSN, CNM

Provider Business Mailing Address
First Line	:	612 BRYAN POINT RD
Second Line	:
City	:	ACCOKEEK
State	:	MD
Zip	:	20607-9602
Country	:	US
Telephone Number	:	240-857-5379
Fax Number	:

Provider Business Practice Location Address
First Line	:	1050 W PERIMETER RD
Second Line	:
City	:	ANDREWS AIR FORCE BASE
State	:	MD
Zip	:	20762-6601
Country	:	US
Telephone Number	:	240-857-5379
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	07/08/2007

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