Provider Demographics
NPI:1003913567
Name:ELLIS, KERRI A (NP)
Entity Type:Individual
Prefix:MS
First Name:KERRI
Middle Name:A
Last Name:ELLIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 MILFORD ST
Mailing Address - Street 2:
Mailing Address - City:UPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01568-1309
Mailing Address - Country:US
Mailing Address - Phone:508-529-7000
Mailing Address - Fax:508-529-7024
Practice Address - Street 1:206 MILFORD ST
Practice Address - Street 2:
Practice Address - City:UPTON
Practice Address - State:MA
Practice Address - Zip Code:01568-1309
Practice Address - Country:US
Practice Address - Phone:508-529-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA233757363LA2100X, 363LP0808X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110073123AMedicaid
Q75266Medicare UPIN
MANP5573Medicare PIN