Healthcare Provider Details

I. General information

NPI: 1124885348
Provider Name (Legal Business Name): K ELLIS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 MOUNTAIN ROAD PL NE # 4953
ALBUQUERQUE NM
87110-7845
US

IV. Provider business mailing address

1209 MOUNTAIN ROAD PL NE # 4953
ALBUQUERQUE NM
87110-7845
US

V. Phone/Fax

Practice location:
  • Phone: 904-252-3606
  • Fax: 505-546-4325
Mailing address:
  • Phone: 904-252-3606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KEISHA ELLIS
Title or Position: AUTHORIZED OFFICIAL/OWNER
Credential:
Phone: 904-252-3606