Provider Demographics
NPI:1144719048
Name:OUELLETTE, ELLEN (MD)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:OUELLETTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1329 GUSDORF RD
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6282
Mailing Address - Country:US
Mailing Address - Phone:575-737-3415
Mailing Address - Fax:575-737-3416
Practice Address - Street 1:1329 GUSDORF RD
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6282
Practice Address - Country:US
Practice Address - Phone:575-737-3415
Practice Address - Fax:575-737-3415
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61072960207Q00000X
390200000X
NMMD2022-1085207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program