Healthcare Provider Details

I. General information

NPI: 1508165853
Provider Name (Legal Business Name): STEPHANIE A ELLIS RRT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2011
Last Update Date: 03/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 HOSPITAL PL
SOLDOTNA AK
99669-7559
US

IV. Provider business mailing address

250 HOSPITAL PL
SOLDOTNA AK
99669-7559
US

V. Phone/Fax

Practice location:
  • Phone: 907-714-4437
  • Fax:
Mailing address:
  • Phone: 907-714-4437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2279C0205X
TaxonomyCritical Care Registered Respiratory Therapist
License NumberA-5583
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: