Provider Demographics
NPI:1841356078
Name:ELLIS, SUSAN CAPRI (LPN)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:CAPRI
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 E BRADFORD ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2921
Mailing Address - Country:US
Mailing Address - Phone:765-251-1508
Mailing Address - Fax:
Practice Address - Street 1:716 E BRADFORD ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2921
Practice Address - Country:US
Practice Address - Phone:765-251-1508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN27041419A164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse