Provider Demographics
NPI:1235864935
Name:ELLIS, MOLLY (RD, DC)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RD, DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3417 SUNNY LN
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53531-9712
Mailing Address - Country:US
Mailing Address - Phone:608-217-8450
Mailing Address - Fax:
Practice Address - Street 1:2500 OVERLOOK TER
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-2254
Practice Address - Country:US
Practice Address - Phone:608-256-1901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI86132541133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered