Provider Demographics
NPI:1902443195
Name:ELLIS, AMANDA L (APRNCNP)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:L
Last Name:ELLIS
Suffix:
Gender:F
Credentials:APRNCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 9TH ST SW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44707-4714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:408 9TH ST SW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44707-4714
Practice Address - Country:US
Practice Address - Phone:330-454-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-06
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.025521363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0414147Medicaid