Provider Demographics
NPI:1346497658
Name:ELLIS, KIRSTEN WILSON (NP)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:WILSON
Last Name:ELLIS
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 1:1350 S ELISEO DR
Mailing Address - Street 2:STE 130
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-2011
Mailing Address - Country:US
Mailing Address - Phone:415-238-0203
Mailing Address - Fax:
Practice Address - Street 1:1350 S ELISEO DR
Practice Address - Street 2:STE 130
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2011
Practice Address - Country:US
Practice Address - Phone:415-238-0203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18219363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA18219OtherSTATE LICENSE