Provider Demographics
NPI:1215814694
Name:ELLIS, SHELLY ANN
Entity type:Individual
Prefix:
First Name:SHELLY ANN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 MAPLE HILL AVE
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-2719
Mailing Address - Country:US
Mailing Address - Phone:631-575-7769
Mailing Address - Fax:
Practice Address - Street 1:30 MAPLE HILL AVE
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-2719
Practice Address - Country:US
Practice Address - Phone:631-575-7769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-19
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY554311163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty