Healthcare Provider Details

I. General information

NPI: 1578484234
Provider Name (Legal Business Name): NICOLE ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10397 N HUALAPAI DR
CASA GRANDE AZ
85122-8083
US

IV. Provider business mailing address

10397 N HUALAPAI DR
CASA GRANDE AZ
85122-8083
US

V. Phone/Fax

Practice location:
  • Phone: 602-214-1377
  • Fax:
Mailing address:
  • Phone: 602-214-1377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: