Provider Demographics
NPI:1164605812
Name:ELLIS, ANDREA P (RN)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:P
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:P
Other - Last Name:MANTARO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:9141 STRATUS CIRLCLE
Mailing Address - Street 2:N/A
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104-2143
Mailing Address - Country:US
Mailing Address - Phone:315-682-3299
Mailing Address - Fax:
Practice Address - Street 1:9141 STRATUS CIRLCLE
Practice Address - Street 2:N/A
Practice Address - City:MANLIUS
Practice Address - State:NY
Practice Address - Zip Code:13104-2143
Practice Address - Country:US
Practice Address - Phone:315-682-3299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-17
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY460520163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse