Provider Demographics
NPI:1588828594
Name:ELLIS, KATRINA KARETHA (LICENSED PRACTICAL)
Entity Type:Individual
Prefix:MRS
First Name:KATRINA
Middle Name:KARETHA
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LICENSED PRACTICAL
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:K
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4533 N 67TH STREET
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218
Mailing Address - Country:US
Mailing Address - Phone:414-461-2977
Mailing Address - Fax:414-461-2977
Practice Address - Street 1:4533 N 67TH STREET
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218
Practice Address - Country:US
Practice Address - Phone:414-461-2977
Practice Address - Fax:414-461-2977
Is Sole Proprietor?:No
Enumeration Date:2008-07-18
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI307461-031364SL0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SL0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistLong-Term Care