Provider Demographics
NPI:1700151560
Name:ELLIS, BEVERLY (FNP)
Entity Type:Individual
Prefix:MS
First Name:BEVERLY
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:BEVERLY
Other - Middle Name:
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:425 E 110TH ST APT 850
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-3344
Mailing Address - Country:US
Mailing Address - Phone:917-774-5093
Mailing Address - Fax:212-722-2428
Practice Address - Street 1:425 E 110TH ST APT 850
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-3344
Practice Address - Country:US
Practice Address - Phone:917-774-5093
Practice Address - Fax:212-722-2428
Is Sole Proprietor?:No
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY249133163W00000X
NYF332344363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse