Provider Demographics
NPI:1013480540
Name:ELLIS, DEBRA ANN
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:ANN
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 1:11 SOUTH RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-2483
Mailing Address - Country:US
Mailing Address - Phone:860-837-5428
Mailing Address - Fax:860-837-7871
Practice Address - Street 1:11 SOUTH RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-2483
Practice Address - Country:US
Practice Address - Phone:860-837-5428
Practice Address - Fax:860-837-7871
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTE60726163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health