Provider Demographics
NPI:1831542281
Name:ELLIS, ANITRA MARIE (NP-C)
Entity type:Individual
Prefix:
First Name:ANITRA
Middle Name:MARIE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:NP-C
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 754
Mailing Address - Street 2:
Mailing Address - City:CHAPMANVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25508-0754
Mailing Address - Country:US
Mailing Address - Phone:304-855-6121
Mailing Address - Fax:
Practice Address - Street 1:50 LENORE BUSINESS CENTER
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661
Practice Address - Country:US
Practice Address - Phone:304-475-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-21
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV81437363LF0000X
WVAPRN81437-NP-C363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner