Provider Demographics
NPI:1891452983
Name:ELLIS, LAURIE JEAN (RN, CDCES)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:JEAN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RN, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 902
Mailing Address - Street 2:
Mailing Address - City:GUERNSEY
Mailing Address - State:WY
Mailing Address - Zip Code:82214-0902
Mailing Address - Country:US
Mailing Address - Phone:307-331-4256
Mailing Address - Fax:
Practice Address - Street 1:24 MILLER ROAD
Practice Address - Street 2:
Practice Address - City:GUERNSEY
Practice Address - State:WY
Practice Address - Zip Code:82214-0902
Practice Address - Country:US
Practice Address - Phone:307-331-4256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY12870163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse