Provider Demographics
NPI:1376840637
Name:ELLIS, PAMELA JEAN (APRN,CRNA)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:JEAN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:APRN,CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 HENNEPIN AVE N
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:MN
Mailing Address - Zip Code:55336-1416
Mailing Address - Country:US
Mailing Address - Phone:320-864-7812
Mailing Address - Fax:
Practice Address - Street 1:1805 HENNEPIN AVE N
Practice Address - Street 2:
Practice Address - City:GLENCOE
Practice Address - State:MN
Practice Address - Zip Code:55336-1416
Practice Address - Country:US
Practice Address - Phone:320-864-3121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-23
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN136088-8163W00000X
MN1982367500000X
IL209008683367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse