Provider Demographics
NPI:1457328734
Name:ELLIS, HORACE A (MSN, A R N P)
Entity Type:Individual
Prefix:MR
First Name:HORACE
Middle Name:A
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MSN, A R N P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10246 SW 24TH CT
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-6504
Mailing Address - Country:US
Mailing Address - Phone:954-435-3696
Mailing Address - Fax:305-355-8091
Practice Address - Street 1:1695 NW 9TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1409
Practice Address - Country:US
Practice Address - Phone:305-355-7228
Practice Address - Fax:305-355-8091
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2180612363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPROFEE AND GROUP #Medicaid
GROUP # 72293Medicare ID - Type UnspecifiedPHT-UM-JMH PROFEE, ER/UCC
FLPROFEE AND GROUP #Medicaid