Provider Demographics
NPI:1376092825
Name:ELLIS, COURTNEY (MNT)
Entity Type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MNT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2253 N DOWNING ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205-5234
Mailing Address - Country:US
Mailing Address - Phone:303-895-8589
Mailing Address - Fax:
Practice Address - Street 1:2253 N DOWNING ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-5234
Practice Address - Country:US
Practice Address - Phone:303-895-8589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education