Provider Demographics
NPI:1760136220
Name:BULLIS, ELLIE (ARNP)
Entity Type:Individual
Prefix:
First Name:ELLIE
Middle Name:
Last Name:BULLIS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:ELLIE
Other - Middle Name:
Other - Last Name:TARR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-356-1616
Mailing Address - Fax:
Practice Address - Street 1:1351 KIMBERLY RD STE 100
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-4193
Practice Address - Country:US
Practice Address - Phone:563-355-7733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-03
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA167150363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAA167150OtherIOWA ARNP LICENSE