Provider Demographics
NPI:1588486989
Name:ELLIS, CAROLINE SUZANNE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MRS
First Name:CAROLINE
Middle Name:SUZANNE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:575-740-7449
Mailing Address - Fax:
Practice Address - Street 1:710 E AVE
Practice Address - Street 2:FAMILY MEDICINE
Practice Address - City:CARRIZOZO
Practice Address - State:NM
Practice Address - Zip Code:88301-0008
Practice Address - Country:US
Practice Address - Phone:575-648-2317
Practice Address - Fax:575-648-4413
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-28
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM81488363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily