Provider Demographics
NPI:1962705103
Name:ELLIS, KELLY ELIZABETH (APN, CNM)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ELIZABETH
Last Name:ELLIS
Suffix:
Gender:
Credentials:APN, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 RIVER RD STE C
Mailing Address - Street 2:
Mailing Address - City:GRANVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43023-9560
Mailing Address - Country:US
Mailing Address - Phone:740-279-3990
Mailing Address - Fax:740-212-8368
Practice Address - Street 1:905 RIVER RD STE C
Practice Address - Street 2:
Practice Address - City:GRANVILLE
Practice Address - State:OH
Practice Address - Zip Code:43023-9560
Practice Address - Country:US
Practice Address - Phone:740-279-3990
Practice Address - Fax:740-212-8368
Is Sole Proprietor?:No
Enumeration Date:2010-12-09
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
367A00000X
IL209008508367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife