Provider Demographics
NPI:1316671449
Name:ELLISON, DEVYN ROCHELLE (NP)
Entity type:Individual
Prefix:
First Name:DEVYN
Middle Name:ROCHELLE
Last Name:ELLISON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DEVYN
Other - Middle Name:ROCHELLE
Other - Last Name:DICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE BOX 635
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-276-4113
Mailing Address - Fax:
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-0001
Practice Address - Country:US
Practice Address - Phone:585-275-4113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2023-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY383412363AM0700X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical