Provider Demographics
NPI:1770578254
Name:ELLIS, LAURIE (NP)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:
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 1:3920 S 1100 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1213
Mailing Address - Country:US
Mailing Address - Phone:801-266-8841
Mailing Address - Fax:801-266-0449
Practice Address - Street 1:3920 S 1100 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1213
Practice Address - Country:US
Practice Address - Phone:801-266-8841
Practice Address - Fax:801-266-0449
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2211674405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP71329Medicare UPIN