Basic Information
| Provider Information | |||||||||
| NPI: | 1700125663 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | LORRAINE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | LORRAINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3701 S BROADWAY | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801133611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033606276 | ||||||||
| FaxNumber: | 3037612787 | ||||||||
| Practice Location | |||||||||
| Address1: | 15501 E 13TH AVE | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800117203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033606276 | ||||||||
| FaxNumber: | 3033431006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2013 | ||||||||
| LastUpdateDate: | 02/11/2019 | ||||||||
| 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 | 163WW0101X | 0062218 | CO | N | Nursing Service Providers | Registered Nurse | Women's Health Care, Ambulatory | 363L00000X | APN.0990405 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 65280555 | 05 | CO | MEDICAID | 016313 | 01 | CO | KAISER COMMERCIAL NUMBER | OTHER |