Basic Information
| Provider Information | |||||||||
| NPI: | 1487736831 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLWOOD | ||||||||
| FirstName: | DIXIE | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 N 4TH ST | ||||||||
| Address2: | |||||||||
| City: | MARTINS FERRY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 439351648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406331100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 90 N 4TH ST | ||||||||
| Address2: | |||||||||
| City: | MARTINS FERRY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 439351648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406331100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 02060 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 0065773000 | 05 | WV | MEDICAID | 2322016 | 05 | OH | MEDICAID |