Provider Demographics
NPI:1376746883
Name:ELLIS, DEBORAH MARIE (CNM APRN)
Entity Type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:MARIE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:CNM APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-233-4200
Mailing Address - Fax:
Practice Address - Street 1:1225 E FORT UNION BLVD
Practice Address - Street 2:STE 215
Practice Address - City:COTTONWOOD HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84047-1889
Practice Address - Country:US
Practice Address - Phone:801-233-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2206804405163W00000X
UT2206804402367A00000X
UT220680-4405363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1841250602OtherNPI FOR LEON HANSEN
UT1841250602OtherNPI FOR LEON HANSEN