Provider Demographics
NPI:1952494916
Name:ELLISON, NINA S (FNP)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:S
Last Name:ELLISON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 2ND AVE S
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55402-3318
Mailing Address - Country:US
Mailing Address - Phone:612-225-1512
Mailing Address - Fax:612-234-4625
Practice Address - Street 1:1008 LAKE MURRAY BLVD
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-2821
Practice Address - Country:US
Practice Address - Phone:612-225-1512
Practice Address - Fax:612-234-4625
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPRN1563363LF0000X
NC5004353363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA33889090Medicare PIN
SCQ31328Medicare UPIN