Healthcare Provider Details

I. General information

NPI: 1588486989
Provider Name (Legal Business Name): CAROLINE SUZANNE ELLIS NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 11/20/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 E AVE FAMILY MEDICINE
CARRIZOZO NM
88301-0008
US

IV. Provider business mailing address

PO BOX 26666
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 575-648-2317
  • Fax: 575-648-4413
Mailing address:
  • Phone: 575-740-7449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number81488
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: