Provider Demographics
NPI:1619579729
Name:ELLIS, NICOLE KATHRYN (NP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:KATHRYN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 S 1ST ST APT A1012
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55401-1852
Mailing Address - Country:US
Mailing Address - Phone:224-563-7527
Mailing Address - Fax:
Practice Address - Street 1:15 S 1ST ST APT A1012
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55401-1852
Practice Address - Country:US
Practice Address - Phone:224-563-7527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7520363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner