Provider Demographics
NPI:1982111639
Name:ELLIS, DANA MICHELLE
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:MICHELLE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DANA
Other - Middle Name:M
Other - Last Name:SIMPKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:550 GAGE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-9532
Mailing Address - Country:US
Mailing Address - Phone:509-942-3627
Mailing Address - Fax:509-627-2983
Practice Address - Street 1:888 SWIFT BLVD
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3514
Practice Address - Country:US
Practice Address - Phone:509-946-4611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-03
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60156492163W00000X
WAAP60813690363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse