Basic Information
Provider Information | |||||||||
NPI: | 1194225631 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ELLIS | ||||||||
FirstName: | KATHERINE | ||||||||
MiddleName: | TRULOVE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 602 WINDMILL RD | ||||||||
Address2: |   | ||||||||
City: | EASTON | ||||||||
State: | MD | ||||||||
PostalCode: | 216012523 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4434543719 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 401 PURDY ST STE 102 | ||||||||
Address2: |   | ||||||||
City: | EASTON | ||||||||
State: | MD | ||||||||
PostalCode: | 216014060 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4108200038 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/20/2018 | ||||||||
LastUpdateDate: | 10/25/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/25/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X | R176261 | MD | N |   | Other Service Providers | Midwife |   | 367A00000X | R176261 | MD | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |   |
No ID Information.