Provider Demographics
NPI:1568536142
Name:ELLIS, HARLEY LYELL (RN, CNP)
Entity Type:Individual
Prefix:
First Name:HARLEY
Middle Name:LYELL
Last Name:ELLIS
Suffix:
Gender:M
Credentials:RN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 8TH ST S
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-4127
Mailing Address - Country:US
Mailing Address - Phone:218-829-0895
Mailing Address - Fax:
Practice Address - Street 1:11855 STATE AVE
Practice Address - Street 2:C.O.R.E. BRAINERD
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-4127
Practice Address - Country:US
Practice Address - Phone:218-828-2389
Practice Address - Fax:218-828-6165
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 092367-9363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily