Provider Demographics
NPI:1508806779
Name:ELLIS, JAMIE L (NPP)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:L
Last Name:ELLIS
Suffix:
Gender:F
Credentials:NPP
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:LIN
Other - Last Name:MIDDLEBROOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9 CAREY RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-7880
Mailing Address - Country:US
Mailing Address - Phone:518-761-0300
Mailing Address - Fax:518-824-2388
Practice Address - Street 1:161 CAREY RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-7821
Practice Address - Country:US
Practice Address - Phone:518-824-8610
Practice Address - Fax:518-824-2390
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400698363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02347437Medicaid
NY02347437Medicaid
NYJ400046705Medicare PIN