MEDICARE: DENISE ELLISON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	22040	CA

General Provider Information

NPI Number	:	1225495757
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENISE ELLISON

Provider Business Mailing Address
First Line	:	3160 GARRITY WAY
Second Line	:
City	:	SAN PABLO
State	:	CA
Zip	:	94806-1983
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3160 GARRITY WAY
Second Line	:
City	:	SAN PABLO
State	:	CA
Zip	:	94806-1983
Country	:	US
Telephone Number	:	510-758-7462
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/28/2016
Last Update Date	:	01/28/2016

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Directions to “ DENISE ELLISON ” Practice Location

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