Basic Information
Provider Information | |||||||||
NPI: | 1518955822 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ELLERTSON | ||||||||
FirstName: | CAROL | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | ARNP, MS, CNM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JAMES | ||||||||
OtherFirstName: | CAROL | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1015 DUFF AVE | ||||||||
Address2: |   | ||||||||
City: | AMES | ||||||||
State: | IA | ||||||||
PostalCode: | 500103014 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5152394414 | ||||||||
FaxNumber: | 5152394786 | ||||||||
Practice Location | |||||||||
Address1: | 1015 DUFF AVE | ||||||||
Address2: |   | ||||||||
City: | AMES | ||||||||
State: | IA | ||||||||
PostalCode: | 500103014 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5152394414 | ||||||||
FaxNumber: | 5152394786 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/11/2005 | ||||||||
LastUpdateDate: | 07/20/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | B059680 | IA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |   |
ID Information
ID | Type | State | Issuer | Description | 0419549 | 05 | IA |   | MEDICAID |