Provider Demographics
NPI:1033677398
Name:IACIOFANO, ELLEN M (PA-C)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:M
Last Name:IACIOFANO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6480 HARRISON AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-7961
Mailing Address - Country:US
Mailing Address - Phone:513-354-3700
Mailing Address - Fax:513-354-3705
Practice Address - Street 1:500 E BUSINESS WAY
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45241-2374
Practice Address - Country:US
Practice Address - Phone:513-354-3700
Practice Address - Fax:513-354-3705
Is Sole Proprietor?:No
Enumeration Date:2019-03-06
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010554363A00000X
OH50.005864RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant