Provider Demographics
NPI:1669003711
Name:ELLISON, KURT MERVIN (LPN)
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:MERVIN
Last Name:ELLISON
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7295 SE CRAIG ST
Mailing Address - Street 2:
Mailing Address - City:HOBE SOUND
Mailing Address - State:FL
Mailing Address - Zip Code:33455-6114
Mailing Address - Country:US
Mailing Address - Phone:570-506-3157
Mailing Address - Fax:
Practice Address - Street 1:1639 FORUM PL STE 7
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-2330
Practice Address - Country:US
Practice Address - Phone:561-712-8821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5222714164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse