Provider Demographics
NPI:1912730052
Name:ELLIS, ALEXA RENEE (MSN, RN, FNP-BC)
Entity type:Individual
Prefix:
First Name:ALEXA
Middle Name:RENEE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MSN, RN, FNP-BC
Other - Prefix:
Other - First Name:ALEXA
Other - Middle Name:RENEE
Other - Last Name:DEMANUEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, RN, FNP-BC
Mailing Address - Street 1:225 COMMUNITY DR RM 110
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 COMMUNITY DR RM 110
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5506
Practice Address - Country:US
Practice Address - Phone:516-365-3996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-23
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY809745163W00000X
NY353283363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse