Healthcare Provider Details

I. General information

NPI: 1285300772
Provider Name (Legal Business Name): MARY VIRGINIA ELLINGTON NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2021
Last Update Date: 01/07/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1871 US41A SOUTH
DIXON KY
42409
US

IV. Provider business mailing address

1871 US HIGHWAY 41A S
DIXON KY
42409-9448
US

V. Phone/Fax

Practice location:
  • Phone: 270-543-6372
  • Fax: 270-440-2109
Mailing address:
  • Phone: 270-249-6037
  • Fax: 270-440-0007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3016526
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: