Healthcare Provider Details

I. General information

NPI: 1992778476
Provider Name (Legal Business Name): EARNESTINE ELLIS APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 02/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7061 GRAND MONTECITO PKWY
LAS VEGAS NV
89149-0287
US

IV. Provider business mailing address

PO BOX 15645
LAS VEGAS NV
89114-5645
US

V. Phone/Fax

Practice location:
  • Phone: 702-750-3900
  • Fax: 702-750-3725
Mailing address:
  • Phone: 702-750-3900
  • Fax: 702-750-3725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberAPN00065
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: