Provider Demographics
NPI:1578904744
Name:ELLIS, LAURA (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 MADISON AVENUE, BOX 1273
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6514
Mailing Address - Country:US
Mailing Address - Phone:650-580-3624
Mailing Address - Fax:
Practice Address - Street 1:1425 MADISON AVENUE, BOX 1273
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6514
Practice Address - Country:US
Practice Address - Phone:650-580-3624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-16
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA833556163W00000X
NJ26NR17280100163W00000X
PARN657785163W00000X
NY22 657365163W00000X
CA95001767363LF0000X
NY33338633363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse