Provider Demographics
NPI:1700239126
Name:ELLIS, ASHLEY ELIZABETH NORUM (OD)
Entity Type:Individual
Prefix:DR
First Name:ASHLEY
Middle Name:ELIZABETH NORUM
Last Name:ELLIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:ELIZABETH
Other - Last Name:NORUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:4169 GEIST RD
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-3420
Mailing Address - Country:US
Mailing Address - Phone:907-479-4700
Mailing Address - Fax:907-457-5596
Practice Address - Street 1:5208 W RENO AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73127
Practice Address - Country:US
Practice Address - Phone:405-948-4900
Practice Address - Fax:405-948-4902
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK112963152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist