Healthcare Provider Details

I. General information

NPI: 1841288339
Provider Name (Legal Business Name): LINDA Y ELLIS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 07/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 17TH ST SUITE A
BAKER CITY OR
97814-1300
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 541-523-1001
  • Fax: 541-523-1152
Mailing address:
  • Phone: 208-381-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number097006942N1
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: