Provider Demographics
NPI:1740677558
Name:ELLIS, CLAIRE E (NP)
Entity type:Individual
Prefix:
First Name:CLAIRE
Middle Name:E
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:PO BOX 950248
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0248
Mailing Address - Country:US
Mailing Address - Phone:812-949-5482
Mailing Address - Fax:812-949-5966
Practice Address - Street 1:4101 TECHNOLOGY AVE
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-8548
Practice Address - Country:US
Practice Address - Phone:812-590-3334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-20
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3009301363LF0000X
IN71005890A363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100374130Medicaid
IN201361760Medicaid
IN201361760Medicaid
KY7100374130Medicaid