Healthcare Provider Details

I. General information

NPI: 1851331508
Provider Name (Legal Business Name): ELLEN C WATSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 07/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 MALLETTS BAY AVE STE B
WINOOSKI VT
05404-1960
US

IV. Provider business mailing address

32 MALLETTS BAY AVE STE B
WINOOSKI VT
05404-1960
US

V. Phone/Fax

Practice location:
  • Phone: 802-655-4422
  • Fax: 802-861-2678
Mailing address:
  • Phone: 802-655-4422
  • Fax: 802-861-2678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number101023489
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: