Provider Demographics
NPI:1629472170
Name:ELLIS, KRISTIN ALEXANDRIA (DO)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:ALEXANDRIA
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 S KANNER HWY STE 200
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-4801
Mailing Address - Country:US
Mailing Address - Phone:772-419-4834
Mailing Address - Fax:
Practice Address - Street 1:3801 S KANNER HWY STE 200
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-4801
Practice Address - Country:US
Practice Address - Phone:772-419-4834
Practice Address - Fax:772-419-4833
Is Sole Proprietor?:No
Enumeration Date:2014-10-13
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS20624208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology