Provider Demographics
NPI:1144516857
Name:ELLIS, CARLY (DO)
Entity type:Individual
Prefix:DR
First Name:CARLY
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:CARLY
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1824 VT 11
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05143-8621
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1824 VT 11
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VT
Practice Address - Zip Code:05143-8621
Practice Address - Country:US
Practice Address - Phone:610-906-5514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-21
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT134060207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine