Healthcare Provider Details

I. General information

NPI: 1316579337
Provider Name (Legal Business Name): MATTIE ROSE ELLENSON APRN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2020
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49725 COUNTY 83
STAPLES MN
56479-5280
US

IV. Provider business mailing address

49725 COUNTY 83
STAPLES MN
56479-5280
US

V. Phone/Fax

Practice location:
  • Phone: 218-894-1515
  • Fax: 218-898-7518
Mailing address:
  • Phone: 218-894-1515
  • Fax: 218-898-7518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number12090
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: