Provider Demographics
NPI:1184191363
Name:ELLIS, JEANETTE ILENE (NURSE ANESTHETIST)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:ILENE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:NURSE ANESTHETIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 APACHE DR
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-4015
Mailing Address - Country:US
Mailing Address - Phone:573-703-3298
Mailing Address - Fax:
Practice Address - Street 1:2 GOOD SAMARITAN WAY STE 205
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2476
Practice Address - Country:US
Practice Address - Phone:618-899-3869
Practice Address - Fax:618-899-3558
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL118890367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered