Healthcare Provider Details

I. General information

NPI: 1831035526
Provider Name (Legal Business Name): ELLIE ANN EIDSVOLD BSN, RN, CPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13001 E 17TH PL
AURORA CO
80045-2570
US

IV. Provider business mailing address

468 S CLARKSON ST
DENVER CO
80209-2128
US

V. Phone/Fax

Practice location:
  • Phone: 952-270-0162
  • Fax:
Mailing address:
  • Phone: 952-270-0162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1674936
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: