Provider Demographics
NPI:1891079430
Name:ELLINGSON, MELISSA ANNE (MSN, PNP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANNE
Last Name:ELLINGSON
Suffix:
Gender:F
Credentials:MSN, PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12455 E 100TH ST N STE 300
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-4678
Mailing Address - Country:US
Mailing Address - Phone:918-274-9700
Mailing Address - Fax:918-274-1395
Practice Address - Street 1:12455 E 100TH ST N STE 300
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-4678
Practice Address - Country:US
Practice Address - Phone:918-274-9700
Practice Address - Fax:918-274-1395
Is Sole Proprietor?:No
Enumeration Date:2011-09-30
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024170262363LP0200X
OK121520363LP0200X
MDR187505363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics