Provider Demographics
NPI:1336986298
Name:ELLIS, KATHERINE (RN-BC)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 E BENTON RD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:ME
Mailing Address - Zip Code:04901-2851
Mailing Address - Country:US
Mailing Address - Phone:207-323-6577
Mailing Address - Fax:
Practice Address - Street 1:67 EUSTIS PKWY
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-5173
Practice Address - Country:US
Practice Address - Phone:207-873-2136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERN66396163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health