Provider Demographics
NPI:1720297096
Name:ELLIS, KATHRYN KRUEGER (NP)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:KRUEGER
Last Name:ELLIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 FOREST DR
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-3627
Mailing Address - Country:US
Mailing Address - Phone:703-534-7178
Mailing Address - Fax:
Practice Address - Street 1:337 MAPLE AVE E.
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180
Practice Address - Country:US
Practice Address - Phone:703-424-1302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1003376363LA2200X
VA0024101218363LA2200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA142866ZCCUMedicare PIN
VAMC12524Medicare PIN