Healthcare Provider Details

I. General information

NPI: 1679570618
Provider Name (Legal Business Name): CAROLYN ANN ELLSWORTH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2005
Last Update Date: 11/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 N KENTUCKY ST
WEST PLAINS MO
65775-2073
US

IV. Provider business mailing address

312 N KENTUCKY ST
WEST PLAINS MO
65775-2073
US

V. Phone/Fax

Practice location:
  • Phone: 417-257-7076
  • Fax: 417-257-1417
Mailing address:
  • Phone: 417-257-7076
  • Fax: 417-257-1417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number102421
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: