Provider Demographics
NPI:1720861438
Name:PRATHER, ELLIS (NP)
Entity type:Individual
Prefix:
First Name:ELLIS
Middle Name:
Last Name:PRATHER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02129-4557
Mailing Address - Country:US
Mailing Address - Phone:413-687-5911
Mailing Address - Fax:
Practice Address - Street 1:2818 ASTORIA BLVD
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-4751
Practice Address - Country:US
Practice Address - Phone:917-410-6905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-16
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY421714363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health