Provider Demographics
NPI:1306272794
Name:ELLIS, MICHELLE DIANE (ATC PTA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DIANE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:ATC PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 S COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4039
Mailing Address - Country:US
Mailing Address - Phone:701-746-8374
Mailing Address - Fax:
Practice Address - Street 1:1425 S COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4039
Practice Address - Country:US
Practice Address - Phone:701-746-8374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-18
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11742255A2300X
MNA877225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant