Provider Demographics
NPI:1275930026
Name:BRAVEHEART, ELLISE CAROLINE (RN, CNP, FNP-C)
Entity Type:Individual
Prefix:
First Name:ELLISE
Middle Name:CAROLINE
Last Name:BRAVEHEART
Suffix:
Gender:F
Credentials:RN, CNP, FNP-C
Other - Prefix:
Other - First Name:ELLISE
Other - Middle Name:
Other - Last Name:CHINN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:907 SLATE ST
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-1252
Mailing Address - Country:US
Mailing Address - Phone:218-269-4974
Mailing Address - Fax:
Practice Address - Street 1:927 TRETTEL LN
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-1345
Practice Address - Country:US
Practice Address - Phone:218-879-1227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-21
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR221785-9163WM0705X
MN9590363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical