Provider Demographics
NPI:1720767114
Name:ELLISON, CASSANDRA BROOKE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:BROOKE
Last Name:ELLISON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 729
Mailing Address - Street 2:
Mailing Address - City:SALTVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24370-0729
Mailing Address - Country:US
Mailing Address - Phone:276-496-4433
Mailing Address - Fax:
Practice Address - Street 1:308 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SALTVILLE
Practice Address - State:VA
Practice Address - Zip Code:24370-3112
Practice Address - Country:US
Practice Address - Phone:276-496-4433
Practice Address - Fax:276-496-5923
Is Sole Proprietor?:No
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024187560363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily