Provider Demographics
NPI:1306485172
Name:ELLIS, HALEY MARIE (CNP)
Entity type:Individual
Prefix:
First Name:HALEY
Middle Name:MARIE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 9TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-1548
Mailing Address - Country:US
Mailing Address - Phone:605-882-7000
Mailing Address - Fax:605-882-7819
Practice Address - Street 1:401 9TH AVE NW
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-1548
Practice Address - Country:US
Practice Address - Phone:605-882-7000
Practice Address - Fax:605-882-7819
Is Sole Proprietor?:No
Enumeration Date:2019-12-27
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR036298163W00000X
SDCP001704363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse