Healthcare Provider Details

I. General information

NPI: 1972454841
Provider Name (Legal Business Name): DIVINIA DEWAYNIA ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2026
Last Update Date: 02/06/2026
Certification Date: 02/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2365 MCKNIGHT RD N
NORTH ST PAUL MN
55109-2238
US

IV. Provider business mailing address

8430 YUCCA LN N
MAPLE GROVE MN
55369-4671
US

V. Phone/Fax

Practice location:
  • Phone: 651-370-2373
  • Fax: 651-370-2373
Mailing address:
  • Phone: 651-370-2373
  • Fax: 651-760-3236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: