Provider Demographics
NPI:1538553136
Name:DIEGO, ELLEN KNOLL (MD)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:KNOLL
Last Name:DIEGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:PATRICIA
Other - Last Name:KNOLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3460 WHITFIELD AVE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45220-1537
Mailing Address - Country:US
Mailing Address - Phone:603-991-9474
Mailing Address - Fax:
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401
Practice Address - Country:US
Practice Address - Phone:802-847-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-23
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VT042.0014070208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program