Basic Information
| Provider Information | |||||||||
| NPI: | 1144993478 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 ATWELL RD | ||||||||
| Address2: | |||||||||
| City: | COOPERSTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 133261394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6075476936 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 739 STATE ROUTE 28 | ||||||||
| Address2: | SUITE 9 | ||||||||
| City: | ONEONTA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6074311015 | ||||||||
| FaxNumber: | 6074311050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2021 | ||||||||
| LastUpdateDate: | 10/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WG0000X | 648053-01 | NY | N | Nursing Service Providers | Registered Nurse | General Practice | 363LF0000X | 348219 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.