Provider Demographics
NPI:1568769552
Name:ELLENSON, NICHOLAS PAUL (DC)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:PAUL
Last Name:ELLENSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21075 SWENSON DR
Mailing Address - Street 2:SUITE 700
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-2000
Mailing Address - Country:US
Mailing Address - Phone:612-590-5155
Mailing Address - Fax:
Practice Address - Street 1:21075 SWENSON DR
Practice Address - Street 2:SUITE 700
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-2000
Practice Address - Country:US
Practice Address - Phone:612-590-5155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-28
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4932 - 12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor