Provider Demographics
NPI:1902040157
Name:ELLISON, ROXANN T (NE HIS #440 / BC-HIS)
Entity Type:Individual
Prefix:
First Name:ROXANN
Middle Name:T
Last Name:ELLISON
Suffix:
Gender:F
Credentials:NE HIS #440 / BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 WEST 7TH STREET
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68801-4221
Mailing Address - Country:US
Mailing Address - Phone:308-382-9169
Mailing Address - Fax:308-382-5088
Practice Address - Street 1:721 WEST 7TH STREET
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68801-4221
Practice Address - Country:US
Practice Address - Phone:308-382-9169
Practice Address - Fax:308-382-5088
Is Sole Proprietor?:No
Enumeration Date:2009-04-30
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE#440237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE470730631-00Medicaid