Provider Demographics
NPI:1083098305
Name:ELLIS, CHARLOTTE
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:ELLIS
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 1:7409 US 42
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-1905
Mailing Address - Country:US
Mailing Address - Phone:859-525-8181
Mailing Address - Fax:859-525-8289
Practice Address - Street 1:7409 US 42
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-1905
Practice Address - Country:US
Practice Address - Phone:859-525-8181
Practice Address - Fax:859-525-8289
Is Sole Proprietor?:No
Enumeration Date:2015-07-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3009558363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics