Provider Demographics
NPI:1932341815
Name:ELLIS, EDNA
Entity type:Individual
Prefix:
First Name:EDNA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2946 PEARSALL AVE
Mailing Address - Street 2:APT# 2
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-5219
Mailing Address - Country:US
Mailing Address - Phone:718-652-2456
Mailing Address - Fax:
Practice Address - Street 1:2946 PEARSALL AVE
Practice Address - Street 2:APT# 2
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-5219
Practice Address - Country:US
Practice Address - Phone:718-652-2456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-24
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY523110163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse