Provider Demographics
NPI:1992074025
Name:ELLESTAD, EMMY ROSE (CRNA)
Entity type:Individual
Prefix:MISS
First Name:EMMY
Middle Name:ROSE
Last Name:ELLESTAD
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Gender:F
Credentials:CRNA
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Mailing Address - Street 1:6500 EXCELSIOR BLVD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-4702
Mailing Address - Country:US
Mailing Address - Phone:651-209-8071
Mailing Address - Fax:651-209-8077
Practice Address - Street 1:333 SMITH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2344
Practice Address - Country:US
Practice Address - Phone:651-735-0501
Practice Address - Fax:651-209-8077
Is Sole Proprietor?:No
Enumeration Date:2011-12-19
Last Update Date:2016-10-17
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Provider Licenses
StateLicense IDTaxonomies
MNR1666935367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered