MEDICARE: NEA D ELLIS RN

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	163W00000X	Registered Nurse	221100-30	WI
2	164W00000X	Licensed Practical Nurse	312273-031	WI

General Provider Information

NPI Number	:	1619250834
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NEA D ELLIS RN

Provider Business Mailing Address
First Line	:	4577 HOGAN LN
Second Line	:
City	:	WADSWORTH
State	:	IL
Zip	:	60083-8943
Country	:	US
Telephone Number	:	414-630-6638
Fax Number	:

Provider Business Practice Location Address
First Line	:	790 N MILWAUKEE ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-3724
Country	:	US
Telephone Number	:	414-207-4860
Fax Number	:

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

Provider Enumeration Date	:	09/23/2011
Last Update Date	:	06/02/2025

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