Healthcare Provider Details

I. General information

NPI: 1528843992
Provider Name (Legal Business Name): DEVA MARIE ELLIS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2023
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5925 LAKEWOOD RANCH BLVD
BRADENTON FL
34211-2464
US

IV. Provider business mailing address

6824 283RD ST E
MYAKKA CITY FL
34251-3300
US

V. Phone/Fax

Practice location:
  • Phone: 941-348-1201
  • Fax:
Mailing address:
  • Phone: 937-504-3049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11028293
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: