Provider Demographics
NPI:1811026610
Name:ELLIS, MARCIA (NP)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17560 CHARTER PINES DR
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-8478
Mailing Address - Country:US
Mailing Address - Phone:719-481-9285
Mailing Address - Fax:
Practice Address - Street 1:3260 E WOODMEN RD STE 210
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-3587
Practice Address - Country:US
Practice Address - Phone:719-262-0852
Practice Address - Fax:719-262-0853
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO94617363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner