Provider Demographics
NPI:1679707871
Name:ELLIS, NICOLE ALEXANDRIA (LAC, LMP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ALEXANDRIA
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LAC, LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1423 WETMORE AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-1635
Mailing Address - Country:US
Mailing Address - Phone:425-830-6765
Mailing Address - Fax:
Practice Address - Street 1:2809 ROCKEFELLER AVE STE A
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3541
Practice Address - Country:US
Practice Address - Phone:425-830-6765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-04
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC 00002475171100000X
WAMA 00018680225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist