Provider Demographics
NPI:1467039446
Name:ELLISON, KIMBERLEE MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:KIMBERLEE
Middle Name:MARIE
Last Name:ELLISON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KIMBERLEE
Other - Middle Name:MARIE
Other - Last Name:HEAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5655 E TEX AL DR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-0406
Mailing Address - Country:US
Mailing Address - Phone:843-276-8694
Mailing Address - Fax:
Practice Address - Street 1:1840 E BROADWAY RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-1614
Practice Address - Country:US
Practice Address - Phone:602-243-7277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-25
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK171645363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily