Basic Information
| Provider Information | |||||||||
| NPI: | 1275758237 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLICE | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 593 EDDY ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014448450 | ||||||||
| FaxNumber: | 4014445088 | ||||||||
| Practice Location | |||||||||
| Address1: | 593 EDDY ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014448450 | ||||||||
| FaxNumber: | 4014445088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2007 | ||||||||
| LastUpdateDate: | 11/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | LP00217 | RI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.