Provider Demographics
NPI:1487690418
Name:ELLIS, KARRIE L (APRN)
Entity type:Individual
Prefix:
First Name:KARRIE
Middle Name:L
Last Name:ELLIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1680 ALBANY AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-1001
Mailing Address - Country:US
Mailing Address - Phone:860-236-4511
Mailing Address - Fax:860-231-8449
Practice Address - Street 1:1680 ALBANY AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105
Practice Address - Country:US
Practice Address - Phone:860-236-4511
Practice Address - Fax:860-231-8449
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001155363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
2111440OtherCIGNA
P46918Medicare UPIN
CT500001521Medicare ID - Type Unspecified