Provider Demographics
NPI:1316579337
Name:ELLENSON, MATTIE (RN, BSN, MPH)
Entity Type:Individual
Prefix:
First Name:MATTIE
Middle Name:
Last Name:ELLENSON
Suffix:
Gender:F
Credentials:RN, BSN, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 W FIR AVE
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-1364
Mailing Address - Country:US
Mailing Address - Phone:218-998-8339
Mailing Address - Fax:
Practice Address - Street 1:560 W FIR AVE
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-1364
Practice Address - Country:US
Practice Address - Phone:218-998-8320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-07
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2149257251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN518853900Medicaid