Provider Demographics
NPI:1841509270
Name:ELLIE, MARY GRACE (RN)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:GRACE
Last Name:ELLIE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:GRACE
Other - Last Name:ELLIE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:811 HARDING STREET
Mailing Address - Street 2:
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981
Mailing Address - Country:US
Mailing Address - Phone:715-258-6385
Mailing Address - Fax:715-258-6409
Practice Address - Street 1:811 HARDING ST
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-2012
Practice Address - Country:US
Practice Address - Phone:715-258-6385
Practice Address - Fax:715-258-6409
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12346230163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health