Provider Demographics
NPI:1902630254
Name:BOLTON, ELLISA ANNE (NP)
Entity type:Individual
Prefix:
First Name:ELLISA
Middle Name:ANNE
Last Name:BOLTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ELLISA
Other - Middle Name:ANNE
Other - Last Name:RUCINSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14828 GREYHOUND CT STE 100
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-5016
Mailing Address - Country:US
Mailing Address - Phone:317-688-5220
Mailing Address - Fax:317-688-5220
Practice Address - Street 1:14828 GREYHOUND CT STE 100
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-5016
Practice Address - Country:US
Practice Address - Phone:317-688-5220
Practice Address - Fax:317-688-5220
Is Sole Proprietor?:No
Enumeration Date:2024-08-29
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28241444A163W00000X
IN71015564A363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300097290Medicaid