Provider Demographics
NPI:1619004413
Name:ELLIS, KIMBERLY ANNE (RN)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANNE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 CLOVERDALE RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14616-3254
Mailing Address - Country:US
Mailing Address - Phone:585-305-6267
Mailing Address - Fax:
Practice Address - Street 1:155 CLOVERDALE RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14616-3254
Practice Address - Country:US
Practice Address - Phone:585-305-6267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY607090-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse