Provider Demographics
NPI:1437481728
Name:MICHELSON, ELLEN (LPN)
Entity type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:
Last Name:MICHELSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 GOLDEN GATE LN
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11967-3711
Mailing Address - Country:US
Mailing Address - Phone:631-399-2654
Mailing Address - Fax:
Practice Address - Street 1:207 HALLOCK RD
Practice Address - Street 2:SUITE 201
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-3033
Practice Address - Country:US
Practice Address - Phone:631-689-8920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-11
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY272435-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse