Provider Demographics
NPI:1265684633
Name:BOERSMA, ELLEN MARIE (NP)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:MARIE
Last Name:BOERSMA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5150 HILL RD E
Mailing Address - Street 2:#F
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-5101
Mailing Address - Country:US
Mailing Address - Phone:707-262-3060
Mailing Address - Fax:
Practice Address - Street 1:5150 HILL RD E
Practice Address - Street 2:#F
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-5101
Practice Address - Country:US
Practice Address - Phone:707-262-3060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18609363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner