MEDICARE: HOLLY ELLISON NP

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	F401175	NY

General Provider Information

NPI Number	:	1720231095
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOLLY ELLISON NP

Provider Business Mailing Address
First Line	:	185 GREEN ST
Second Line	:	SUITE 2
City	:	KINGSTON
State	:	NY
Zip	:	12401-3716
Country	:	US
Telephone Number	:	845-339-3736
Fax Number	:	845-339-6731

Provider Business Practice Location Address
First Line	:	185 GREEN ST
Second Line	:	SUITE 2
City	:	KINGSTON
State	:	NY
Zip	:	12401-3716
Country	:	US
Telephone Number	:	845-339-3736
Fax Number	:	845-339-6731

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

Provider Enumeration Date	:	10/29/2008
Last Update Date	:	10/29/2008

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