Healthcare Provider Details

I. General information

NPI: 1922288380
Provider Name (Legal Business Name): MARY JEAN ELLSWORTH RN, PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2007
Last Update Date: 07/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 W MAIN ST
VISALIA CA
93291-4599
US

IV. Provider business mailing address

330 CAMPUS DR
HANFORD CA
93230-4375
US

V. Phone/Fax

Practice location:
  • Phone: 559-624-1097
  • Fax: 559-624-1086
Mailing address:
  • Phone: 559-582-3211
  • Fax: 559-584-5672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number155127
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: