Healthcare Provider Details

I. General information

NPI: 1790705549
Provider Name (Legal Business Name): DONNA RUTH ELLSWORTH MSN, NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 06/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8405 W ALAMEDA AVE
LAKEWOOD CO
80226-2908
US

IV. Provider business mailing address

11700 W 2ND PL STE 450
LAKEWOOD CO
80228-1719
US

V. Phone/Fax

Practice location:
  • Phone: 720-974-5400
  • Fax: 720-974-4990
Mailing address:
  • Phone: 607-349-8450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number17590
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: