Provider Demographics
NPI:1508318494
Name:ELLIS, KEISHA (NP)
Entity Type:Individual
Prefix:
First Name:KEISHA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 W COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5211
Mailing Address - Country:US
Mailing Address - Phone:575-624-4922
Mailing Address - Fax:575-624-4902
Practice Address - Street 1:603 W COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5211
Practice Address - Country:US
Practice Address - Phone:575-624-4922
Practice Address - Fax:575-624-4902
Is Sole Proprietor?:No
Enumeration Date:2016-10-26
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9281197363LF0000X
NMCNP-03387363LP0808X
NMCNP03387363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM44672322Medicaid