MEDICARE: DURIYYAH ELLIS CRNP

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	SP031365	PA

General Provider Information

NPI Number	:	1932924685
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DURIYYAH ELLIS CRNP

Provider Business Mailing Address
First Line	:	130 N 2ND ST UNIT 1A
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19106-4604
Country	:	US
Telephone Number	:	251-901-3011
Fax Number	:

Provider Business Practice Location Address
First Line	:	130 N 2ND ST UNIT 1A
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19106-4604
Country	:	US
Telephone Number	:	251-901-3011
Fax Number	:

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

Provider Enumeration Date	:	11/18/2024
Last Update Date	:	12/06/2024

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