Provider Demographics
NPI:1447257324
Name:BIVENS, ELLEN
Entity type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:
Last Name:BIVENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 N KENTUCKY ST
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-2073
Mailing Address - Country:US
Mailing Address - Phone:417-257-7076
Mailing Address - Fax:417-257-1417
Practice Address - Street 1:312 N KENTUCKY ST
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-2073
Practice Address - Country:US
Practice Address - Phone:417-257-7076
Practice Address - Fax:417-257-1417
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO120310363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202169405Medicaid