Provider Demographics
NPI:1285017681
Name:TAN, ELLIE (MSN, CNM, WHNP-BC)
Entity Type:Individual
Prefix:
First Name:ELLIE
Middle Name:
Last Name:TAN
Suffix:
Gender:F
Credentials:MSN, CNM, WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6707 N 19TH AVE STE 222
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-1106
Mailing Address - Country:US
Mailing Address - Phone:602-283-3668
Mailing Address - Fax:877-977-9438
Practice Address - Street 1:6707 N 19TH AVE STE 222
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-1106
Practice Address - Country:US
Practice Address - Phone:602-283-3668
Practice Address - Fax:877-977-9438
Is Sole Proprietor?:No
Enumeration Date:2015-07-02
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP7917363LW0102X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health