Healthcare Provider Details

I. General information

NPI: 1588229256
Provider Name (Legal Business Name): ANGELA ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2019
Last Update Date: 05/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20333 W 151ST ST
OLATHE KS
66061-5350
US

IV. Provider business mailing address

PO BOX 75443
CHICAGO IL
60675-5443
US

V. Phone/Fax

Practice location:
  • Phone: 913-791-4200
  • Fax: 913-782-2381
Mailing address:
  • Phone: 717-263-5562
  • Fax: 717-263-1566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number13-112223-062
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: