Provider Demographics
NPI:1851800460
Name:ELLIS, MELISSA (RN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 LAKE ROAD
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:ME
Mailing Address - Zip Code:04294
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:91 SCRIBNER RD
Practice Address - Street 2:
Practice Address - City:TYNGSBORO
Practice Address - State:MA
Practice Address - Zip Code:01879-2378
Practice Address - Country:US
Practice Address - Phone:207-491-4598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-26
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2306804163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice