Provider Demographics
NPI:1407479561
Name:ELLYSON, KATLYN ALEXANDER (RN)
Entity Type:Individual
Prefix:
First Name:KATLYN
Middle Name:ALEXANDER
Last Name:ELLYSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11803 NE 124TH AVE APT 38
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-2095
Mailing Address - Country:US
Mailing Address - Phone:360-450-8700
Mailing Address - Fax:
Practice Address - Street 1:1601 E 4TH PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-3713
Practice Address - Country:US
Practice Address - Phone:360-397-8246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-24
Last Update Date:2020-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN61059962163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse