Healthcare Provider Details

I. General information

NPI: 1619163946
Provider Name (Legal Business Name): ROSEMARY ELLIS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2007
Last Update Date: 12/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11555 1/2 POTRERO RD
BANNING CA
92220-6946
US

IV. Provider business mailing address

11555 1/2 POTRERO RD
BANNING CA
92220-6946
US

V. Phone/Fax

Practice location:
  • Phone: 951-849-4761
  • Fax:
Mailing address:
  • Phone: 951-849-4761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number383483
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: