Provider Demographics
NPI:1275587180
Name:ELY, J ROYE (NP)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:ROYE
Last Name:ELY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 238
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-0238
Mailing Address - Country:US
Mailing Address - Phone:208-664-3301
Mailing Address - Fax:877-653-2694
Practice Address - Street 1:1052 W MILL AVE
Practice Address - Street 2:
Practice Address - City:COEUR D'ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814
Practice Address - Country:US
Practice Address - Phone:208-664-3301
Practice Address - Fax:877-653-2694
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-368A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID13418951Medicare PIN
IDS58109Medicare UPIN