Provider Demographics
NPI:1396820452
Name:ELLINGSON, LORI (FNP)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:ELLINGSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 25TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2367
Mailing Address - Country:US
Mailing Address - Phone:701-241-1360
Mailing Address - Fax:701-241-8559
Practice Address - Street 1:1240 25TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2367
Practice Address - Country:US
Practice Address - Phone:701-241-1360
Practice Address - Fax:701-241-8559
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR23711363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN264304900Medicaid
MN167M7LAOtherBCBS
ND19638OtherBCBS
MN167M7LAOtherBCBS
NDP25944Medicare UPIN