Basic Information
| Provider Information | |||||||||
| NPI: | 1740677558 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | CLAIRE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 950248 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129495482 | ||||||||
| FaxNumber: | 8129495966 | ||||||||
| Practice Location | |||||||||
| Address1: | 7725 HIGHWAY 62 | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CHARLESTOWN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471119637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8125424670 | ||||||||
| FaxNumber: | 8129857676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2015 | ||||||||
| LastUpdateDate: | 03/31/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3009301 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 71005890A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 201361760 | 05 | IN | MEDICAID | 7100374130 | 05 | KY | MEDICAID |