Provider Demographics
NPI:1902955131
Name:ELLISON, ARDYTHE K (RN, MSN, CNM)
Entity Type:Individual
Prefix:MS
First Name:ARDYTHE
Middle Name:K
Last Name:ELLISON
Suffix:
Gender:F
Credentials:RN, MSN, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 BRYAN POINT RD
Mailing Address - Street 2:
Mailing Address - City:ACCOKEEK
Mailing Address - State:MD
Mailing Address - Zip Code:20607-9602
Mailing Address - Country:US
Mailing Address - Phone:240-857-5379
Mailing Address - Fax:
Practice Address - Street 1:1050 W PERIMETER RD
Practice Address - Street 2:
Practice Address - City:ANDREWS AIR FORCE BASE
Practice Address - State:MD
Practice Address - Zip Code:20762-6601
Practice Address - Country:US
Practice Address - Phone:240-857-5379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV36610176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife