Provider Demographics
NPI:1811052145
Name:ELLMORE, JOAN R (CRNP)
Entity type:Individual
Prefix:MRS
First Name:JOAN
Middle Name:R
Last Name:ELLMORE
Suffix:
Gender:F
Credentials:CRNP
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Other - Credentials:
Mailing Address - Street 1:2101 EAST JEFFERSON STREET PPQA MEDICARE COMPLIANCE UNI
Mailing Address - Street 2:KAISER PERMANENTE MID ATLANTIC PERMANENTE MEDICAL GROUP
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-6660
Mailing Address - Fax:301-816-6308
Practice Address - Street 1:1301 SAM PERRY BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-8420
Practice Address - Country:US
Practice Address - Phone:540-741-3716
Practice Address - Fax:540-741-1096
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0001073375363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P57305Medicare UPIN
005655K32Medicare ID - Type Unspecified