Provider Demographics
NPI:1821750779
Name:ELLIS, SHANNON (NP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9 INDUSTRIAL RD STE 5
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01757-3736
Mailing Address - Country:US
Mailing Address - Phone:508-473-1480
Mailing Address - Fax:
Practice Address - Street 1:1280 W CENTRAL ST STE 301
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:MA
Practice Address - Zip Code:02038-3110
Practice Address - Country:US
Practice Address - Phone:508-528-2700
Practice Address - Fax:508-528-5759
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2283834363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily