Provider Demographics
NPI:1689439341
Name:ELLIS, SUMMERLYN
Entity Type:Individual
Prefix:
First Name:SUMMERLYN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 SW INDIAN AVE
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-3037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1020 SW INDIAN AVE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-3037
Practice Address - Country:US
Practice Address - Phone:541-923-6024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10022072363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily