MEDICARE: MRS. GENIE MARIE ELLIS FNP

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	363LF0000X	Family Nurse Practitioner	0229CNP	SD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649233677
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GENIE MARIE ELLIS FNP

Provider Business Mailing Address
First Line	:	3200 CANYON LAKE DR
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-8114
Country	:	US
Telephone Number	:	605-355-2443
Fax Number	:	650-355-2403

Provider Business Practice Location Address
First Line	:	3200 CANYON LAKE DR
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-8114
Country	:	US
Telephone Number	:	605-355-2443
Fax Number	:	650-355-2403

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

Provider Enumeration Date	:	04/10/2006
Last Update Date	:	11/08/2011

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