Provider Demographics
NPI:1144263526
Name:ELLIS, MELISSA (CRNA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 560727
Mailing Address - Street 2:ANESTHESIA DEPARTMENT
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28256-0727
Mailing Address - Country:US
Mailing Address - Phone:704-863-5664
Mailing Address - Fax:704-863-5848
Practice Address - Street 1:8800 N TRYON ST
Practice Address - Street 2:ANESTHESIA DEPARTMENT
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-3300
Practice Address - Country:US
Practice Address - Phone:704-863-5664
Practice Address - Fax:704-863-5848
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC048241367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8051256Medicaid
SCNAN649Medicaid
NC2618054Medicare PIN
NC8051256Medicaid