Provider Demographics
NPI:1972191195
Name:ELLIS, KIMBERLY (APRN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 LOGAN ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:WV
Mailing Address - Zip Code:25661-3606
Mailing Address - Country:US
Mailing Address - Phone:304-236-5902
Mailing Address - Fax:304-235-8150
Practice Address - Street 1:104 LOGAN ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-3606
Practice Address - Country:US
Practice Address - Phone:304-236-5902
Practice Address - Fax:304-235-8150
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV44540363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily