Provider Demographics
NPI:1801472105
Name:ELLIS, MERCEDES (RN)
Entity type:Individual
Prefix:
First Name:MERCEDES
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2477 WAITS RIVER RD
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:VT
Mailing Address - Zip Code:05033-8104
Mailing Address - Country:US
Mailing Address - Phone:603-667-8337
Mailing Address - Fax:
Practice Address - Street 1:2477 WAITS RIVER RD
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:VT
Practice Address - Zip Code:05033-8104
Practice Address - Country:US
Practice Address - Phone:603-667-8337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-18
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT025.0135464164W00000X
VT026.0146370163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse