Provider Demographics
NPI:1295890259
Name:ELLIS, GAYLE M
Entity type:Individual
Prefix:
First Name:GAYLE
Middle Name:M
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 1:700 RAY O VAC DR
Mailing Address - Street 2:SUITE 220
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-2479
Mailing Address - Country:US
Mailing Address - Phone:608-276-9191
Mailing Address - Fax:608-276-9144
Practice Address - Street 1:700 RAY O VAC DR
Practice Address - Street 2:SUITE 220
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-2479
Practice Address - Country:US
Practice Address - Phone:608-276-9191
Practice Address - Fax:608-276-9144
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2432-057103TC0700X
WI1526-033363LP0808X
WI163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Not Answered163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3914300Medicaid