Provider Demographics
NPI:1710752035
Name:ELLSTROM, KATIE ROSE (DNP, RN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:ROSE
Last Name:ELLSTROM
Suffix:
Gender:F
Credentials:DNP, RN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29500 SOUTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2030
Mailing Address - Country:US
Mailing Address - Phone:248-765-1795
Mailing Address - Fax:
Practice Address - Street 1:29500 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2030
Practice Address - Country:US
Practice Address - Phone:248-765-1795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-16
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704339527363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health