Provider Demographics
NPI:1932816766
Name:LANDREVILLE, ELLIE KATHRYN
Entity type:Individual
Prefix:
First Name:ELLIE
Middle Name:KATHRYN
Last Name:LANDREVILLE
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 1:720 W VIRGINIA ST APT 601
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-1511
Mailing Address - Country:US
Mailing Address - Phone:262-323-2081
Mailing Address - Fax:
Practice Address - Street 1:720 W VIRGINIA ST APT 601
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-1511
Practice Address - Country:US
Practice Address - Phone:262-323-2081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-01
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant