Provider Demographics
NPI:1801401237
Name:ELLIS, EMILY CAMILLE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:CAMILLE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5350 CHRISTI DR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48091-4195
Mailing Address - Country:US
Mailing Address - Phone:616-516-1351
Mailing Address - Fax:
Practice Address - Street 1:5350 CHRISTI DR
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-4195
Practice Address - Country:US
Practice Address - Phone:616-516-1351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-11
Last Update Date:2020-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704329116363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily