Provider Demographics
NPI:1093146482
Name:ELLIS, CYNTHIA ROSE (RN)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:ROSE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3625 COPPERFIELD DR
Mailing Address - Street 2:APT 216
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95136-4066
Mailing Address - Country:US
Mailing Address - Phone:501-366-9762
Mailing Address - Fax:
Practice Address - Street 1:2250 SOQUEL AVE
Practice Address - Street 2:SUITE 150
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-1402
Practice Address - Country:US
Practice Address - Phone:831-600-2801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-10
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA822784163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse