Provider Demographics
NPI:1588866305
Name:ELLIS, MISTY D (APRN)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:D
Last Name:ELLIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:D
Other - Last Name:BOURNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:231 E CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1821
Practice Address - Country:US
Practice Address - Phone:502-629-6000
Practice Address - Fax:502-629-5865
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3005293363LP0200X, 363LA2100X, 363LP0222X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100026490Medicaid
IN200892820Medicaid
IN200892820Medicaid