=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376993709
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE ELLSWORTH ARNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2016
-----------------------------------------------------
Last Update Date | 09/14/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3426 N PORT DR STE 100
-----------------------------------------------------
City | MUSCATINE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52761-2242
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-262-4101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 HAWKINS DRIVE DEPARTMENT OF INTERNAL MEDICINE
-----------------------------------------------------
City | IOWA CITY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52242-1009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-356-1616
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | A132211
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | A132211
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------