Provider Demographics
NPI:1578274684
Name:ELLIS, CRYSTAL (LPN)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10603-2427
Mailing Address - Country:US
Mailing Address - Phone:914-761-0600
Mailing Address - Fax:914-761-5367
Practice Address - Street 1:11 W PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-2017
Practice Address - Country:US
Practice Address - Phone:914-668-8938
Practice Address - Fax:914-668-2545
Is Sole Proprietor?:No
Enumeration Date:2022-12-09
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY344728164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse