Provider Demographics
NPI:1790105948
Name:ELLIS, MARY
Entity Type:Individual
Prefix:
First Name:MARY
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 1:825 S 169TH ST FL 3
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68118-9300
Mailing Address - Country:US
Mailing Address - Phone:402-354-4822
Mailing Address - Fax:402-354-5454
Practice Address - Street 1:2560 N HEALTHY WAY
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-2315
Practice Address - Country:US
Practice Address - Phone:029-417-2454
Practice Address - Fax:402-941-7244
Is Sole Proprietor?:No
Enumeration Date:2014-04-25
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE55813163WP0808X
NE113044363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health