Provider Demographics
NPI:1407377153
Name:ELLIS, MARIE CATHERINE
Entity Type:Individual
Prefix:MISS
First Name:MARIE
Middle Name:CATHERINE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 PINE STREET
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14025
Mailing Address - Country:US
Mailing Address - Phone:716-548-6928
Mailing Address - Fax:
Practice Address - Street 1:140 PINE STREET
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14025
Practice Address - Country:US
Practice Address - Phone:716-646-4991
Practice Address - Fax:716-464-4990
Is Sole Proprietor?:No
Enumeration Date:2017-07-03
Last Update Date:2017-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234409-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse