Provider Demographics
NPI:1063982312
Name:ANDERSON, ELLEN L (RN)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26219 STUDENT
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-3962
Mailing Address - Country:US
Mailing Address - Phone:313-506-8568
Mailing Address - Fax:
Practice Address - Street 1:3956 MOUNT ELLIOTT ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-1841
Practice Address - Country:US
Practice Address - Phone:313-506-8568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704119285163WC1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development