Healthcare Provider Details

I. General information

NPI: 1619004413
Provider Name (Legal Business Name): KIMBERLY ANNE ELLIS R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 07/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 CLOVERDALE RD
ROCHESTER NY
14616-3254
US

IV. Provider business mailing address

155 CLOVERDALE RD
ROCHESTER NY
14616-3254
US

V. Phone/Fax

Practice location:
  • Phone: 585-305-6267
  • Fax:
Mailing address:
  • Phone: 585-305-6267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number607090-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: