Provider Demographics
NPI:1871631796
Name:ELLIS, SUSAN (PNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2048 MISSISSIPPI VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MUSCATINE
Mailing Address - State:IA
Mailing Address - Zip Code:52761-8326
Mailing Address - Country:US
Mailing Address - Phone:563-264-1990
Mailing Address - Fax:
Practice Address - Street 1:1609 CEDAR ST
Practice Address - Street 2:
Practice Address - City:MUSCATINE
Practice Address - State:IA
Practice Address - Zip Code:52761-3426
Practice Address - Country:US
Practice Address - Phone:563-263-0122
Practice Address - Fax:563-263-0520
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAC-079193363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA22315OtherBLUE CROSS BLUE SHIELD
IAI0932Medicare ID - Type Unspecified
IAP17313Medicare UPIN