Provider Demographics
NPI:1922871599
Name:ELLIS, BONNIE J
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:J
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 SILVER ST
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-6514
Mailing Address - Country:US
Mailing Address - Phone:207-877-5068
Mailing Address - Fax:207-872-6014
Practice Address - Street 1:689 HOGAN RD
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3605
Practice Address - Country:US
Practice Address - Phone:207-873-1131
Practice Address - Fax:207-872-6014
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME224P00000X, 222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1669590147Medicaid