Provider Demographics
NPI:1447085899
Name:MEDVED, ELLEN MINICK (FNP-C)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:MINICK
Last Name:MEDVED
Suffix:
Gender:
Credentials:FNP-C
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:ELIZABETH
Other - Last Name:MINICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:5015 ROSEDOWN PL
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-6305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1475 HOLCOMB BRIDGE RD STE 129
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-2126
Practice Address - Country:US
Practice Address - Phone:678-525-1962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-05
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN077255363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily