Provider Demographics
NPI:1366416190
Name:ELLIS, COLEEN ANN (MD)
Entity type:Individual
Prefix:
First Name:COLEEN
Middle Name:ANN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 10TH ST E
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:FL
Mailing Address - Zip Code:34221-4134
Mailing Address - Country:US
Mailing Address - Phone:941-847-7903
Mailing Address - Fax:941-847-7919
Practice Address - Street 1:1120 10TH ST E
Practice Address - Street 2:
Practice Address - City:PALMETTO
Practice Address - State:FL
Practice Address - Zip Code:34221-4134
Practice Address - Country:US
Practice Address - Phone:941-847-7903
Practice Address - Fax:941-847-7919
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87898207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL271958400Medicaid
FL271958400Medicaid
FL50132ZMedicare PIN