Provider Demographics
NPI:1952921538
Name:ELLIS, KASEY DAKOTA BLUE (RN)
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:DAKOTA BLUE
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 1:1985 MCVEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-4219
Mailing Address - Country:US
Mailing Address - Phone:304-654-7004
Mailing Address - Fax:
Practice Address - Street 1:1340 HAL GREER BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3804
Practice Address - Country:US
Practice Address - Phone:304-526-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-23
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV90998163W00000X
WV106823367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse