Provider Demographics
NPI:1700092947
Name:ELLIS, VICTORIA T (CRNP)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:T
Last Name:ELLIS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:500 GROVE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HADDON HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:08035-1761
Mailing Address - Country:US
Mailing Address - Phone:856-796-9200
Mailing Address - Fax:856-796-9397
Practice Address - Street 1:2475 MCCLELLAN AVE
Practice Address - Street 2:SUITE B201
Practice Address - City:PENNSAUKEN
Practice Address - State:NJ
Practice Address - Zip Code:08109-4683
Practice Address - Country:US
Practice Address - Phone:856-330-6300
Practice Address - Fax:856-330-6305
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PASP009134363L00000X
NJ26NJ00335300363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0360210Medicaid
NJ347600C04Medicare PIN