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General NPI Number Information
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NPI Number | 1972454841
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Entity Type | Individual
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Provider Name | DIVINIA DEWAYNIA ELLIS
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Gender | Female
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Dates
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Enumeration Date | 02/06/2026
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Last Update Date | 02/06/2026
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Provider Practice Location Address
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Address Line | 2365 MCKNIGHT RD N
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City | NORTH ST PAUL
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State | MN
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Zip | 55109-2238
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Country | US
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Telephone | 651-370-2373
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Fax | 651-370-2373
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Provider Business Mailing Address
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Address Line | 8430 YUCCA LN N
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City | MAPLE GROVE
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State | MN
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Zip | 55369-4671
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Country | US
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Telephone | 651-370-2373
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Fax | 651-760-3236
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State | MN
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