MEDICARE: ERICA MARIE ELLUL RN, MSN, AGACNP-BC

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	363LA2100X	Acute Care Nurse Practitioner	4704242320	MI

General Provider Information

NPI Number	:	1720502594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERICA MARIE ELLUL RN, MSN, AGACNP-BC

Provider Business Mailing Address
First Line	:	41672 W VILLAGE GREEN BLVD APT 205
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48187-3875
Country	:	US
Telephone Number	:	313-613-1657
Fax Number	:

Provider Business Practice Location Address
First Line	:	1537 MONROE ST STE 100
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48124-2842
Country	:	US
Telephone Number	:	313-359-2100
Fax Number	:	313-359-2104

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

Provider Enumeration Date	:	08/02/2017
Last Update Date	:	08/02/2017

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