Provider Demographics
NPI:1467087064
Name:ELLENA, DEVON SIMONE (NP)
Entity Type:Individual
Prefix:
First Name:DEVON
Middle Name:SIMONE
Last Name:ELLENA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-4400
Mailing Address - Fax:
Practice Address - Street 1:14655 GALAXIE AVE
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-8602
Practice Address - Country:US
Practice Address - Phone:952-432-6161
Practice Address - Fax:952-891-3921
Is Sole Proprietor?:No
Enumeration Date:2020-03-04
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN7290363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology