Basic Information
Provider Information | |||||||||
NPI: | 1225398373 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ELLINGSON | ||||||||
FirstName: | MEGAN | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2355 HIGHWAY 36 W STE 100 | ||||||||
Address2: |   | ||||||||
City: | ROSEVILLE | ||||||||
State: | MN | ||||||||
PostalCode: | 551133905 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512922000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2355 HIGHWAY 36 W STE 100 | ||||||||
Address2: |   | ||||||||
City: | ROSEVILLE | ||||||||
State: | MN | ||||||||
PostalCode: | 551133905 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512922000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2012 | ||||||||
LastUpdateDate: | 07/12/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/12/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R180131-8 | MN | N |   | Nursing Service Providers | Registered Nurse |   | 363LF0000X | R180131-8 | MN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.