Basic Information
| Provider Information | |||||||||
| NPI: | 1891782363 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCANDREW | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PIQUETTE | ||||||||
| OtherFirstName: | ELLEN | ||||||||
| OtherMiddleName: | F | ||||||||
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| OtherNameSuffix: | |||||||||
| OtherCredential: | CNM | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 125 MASCOMA ST | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037662647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034483121 | ||||||||
| FaxNumber: | 6034487462 | ||||||||
| Practice Location | |||||||||
| Address1: | 57 MASCOMA ST | ||||||||
| Address2: | SUITE G1-1 | ||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037662642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034425677 | ||||||||
| FaxNumber: | 6034487462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 01/26/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 0196842301 | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 1002476 | 05 | VT | MEDICAID | 00005558 | 01 | VT | BC BS VT | OTHER | 22470Y | 01 | NH | ANTHEM UPIN | OTHER | 30343027 | 05 | NH | MEDICAID |