Healthcare Provider Details

I. General information

NPI: 1356375935
Provider Name (Legal Business Name): PRISCILLA L ELLINOR RN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 1ST AVE S
FARGO ND
58122-0001
US

IV. Provider business mailing address

700 1ST AVE S
FARGO ND
58122-0001
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-4036
  • Fax: 701-234-4003
Mailing address:
  • Phone: 701-234-4036
  • Fax: 701-234-4003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN.242052-COA1
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR32307
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: