Provider Demographics
NPI:1790105948
Name:ELLIS, MARY (APRN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 E CONDRON ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY
Mailing Address - State:NE
Mailing Address - Zip Code:68064-3401
Mailing Address - Country:US
Mailing Address - Phone:402-871-6010
Mailing Address - Fax:402-359-2702
Practice Address - Street 1:223 E CONDRON ST
Practice Address - Street 2:
Practice Address - City:VALLEY
Practice Address - State:NE
Practice Address - Zip Code:68064-3401
Practice Address - Country:US
Practice Address - Phone:402-517-7646
Practice Address - Fax:402-359-2702
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-25
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1130442084P0800X, 363LP0808X
NE55813163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health