Provider Demographics
NPI:1992778476
Name:ELLIS, EARNESTINE (APN)
Entity type:Individual
Prefix:
First Name:EARNESTINE
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:APN
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 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-750-3900
Mailing Address - Fax:702-750-3725
Practice Address - Street 1:7061 GRAND MONTECITO PKWY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-0287
Practice Address - Country:US
Practice Address - Phone:702-750-3900
Practice Address - Fax:702-750-3725
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPN00065363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2402055Medicaid
NVV35687Medicare PIN
NV31443Medicare ID - Type Unspecified
S64731Medicare UPIN