Provider Demographics
NPI:1932454055
Name:ELLIS, NATHANAEL (NP)
Entity Type:Individual
Prefix:
First Name:NATHANAEL
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:NP
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 636256
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6256
Mailing Address - Country:US
Mailing Address - Phone:513-245-3600
Mailing Address - Fax:513-245-3672
Practice Address - Street 1:4900 HOUSTON RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-4824
Practice Address - Country:US
Practice Address - Phone:859-212-5441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-14
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH332898163W00000X
IN28202989A163W00000X
KY3012203363L00000X
IN71004030A363LF0000X
OHCOA.13515-NP363LF0000X
OHAPRN.CNP.13515363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100302330Medicaid