Healthcare Provider Details

I. General information

NPI: 1912413907
Provider Name (Legal Business Name): ELLERY ANN CONWAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2017
Last Update Date: 12/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 DODGE CT
NEWPORT RI
02840-2114
US

IV. Provider business mailing address

8 DODGE CT
NEWPORT RI
02840-2114
US

V. Phone/Fax

Practice location:
  • Phone: 401-862-3561
  • Fax:
Mailing address:
  • Phone: 401-862-3561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: