Provider Demographics
NPI:1184062671
Name:ELLIS, JUANITA (MSN, APRN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:JUANITA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MSN, APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 N MICHIGAN ST STE 224
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-6941
Mailing Address - Country:US
Mailing Address - Phone:419-963-4299
Mailing Address - Fax:
Practice Address - Street 1:151 N MICHIGAN ST STE 224
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604-6941
Practice Address - Country:US
Practice Address - Phone:419-963-4299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-06
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 139813-M-IV164W00000X
OHRN.410281363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No164W00000XNursing Service ProvidersLicensed Practical Nurse