Basic Information
Provider Information | |||||||||
NPI: | 1700092947 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ELLIS | ||||||||
FirstName: | VICTORIA | ||||||||
MiddleName: | T | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 500 GROVE ST | ||||||||
Address2: | SUITE 100 | ||||||||
City: | HADDON HEIGHTS | ||||||||
State: | NJ | ||||||||
PostalCode: | 080351761 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8567969200 | ||||||||
FaxNumber: | 8567969397 | ||||||||
Practice Location | |||||||||
Address1: | 2475 MCCLELLAN AVE | ||||||||
Address2: | SUITE B201 | ||||||||
City: | PENNSAUKEN | ||||||||
State: | NJ | ||||||||
PostalCode: | 081094683 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8563306300 | ||||||||
FaxNumber: | 8563306305 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/15/2007 | ||||||||
LastUpdateDate: | 10/27/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | SP009134 | PA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LP0200X | 26NJ00335300 | NJ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
ID | Type | State | Issuer | Description | 0360210 | 05 | NJ |   | MEDICAID |