Healthcare Provider Details

I. General information

NPI: 1710456132
Provider Name (Legal Business Name): MRS. MEGAN ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2018
Last Update Date: 03/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4130 SW 117TH AVE STE D
BEAVERTON OR
97005-4632
US

IV. Provider business mailing address

6700 WASHINGTON AVE S
EDEN PRAIRIE MN
55344-3405
US

V. Phone/Fax

Practice location:
  • Phone: 503-591-7027
  • Fax: 503-642-9435
Mailing address:
  • Phone: 800-328-8602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHAS-P-10195072
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: