Provider Demographics
NPI:1528056611
Name:ELLENA, COURTNEY BREAUX (CNM)
Entity type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:BREAUX
Last Name:ELLENA
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:BREAUX
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9195 GRANT ST STE 410
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80229-4388
Mailing Address - Country:US
Mailing Address - Phone:303-280-2229
Mailing Address - Fax:303-280-0765
Practice Address - Street 1:9195 GRANT ST STE 410
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80229-4388
Practice Address - Country:US
Practice Address - Phone:303-280-2229
Practice Address - Fax:303-280-0765
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
APN.0004415-CNM367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO98582232Medicaid
CO37987551OtherMEDICAID PRACTICE GROUP #
CO98582232Medicaid
COC300729OtherEXEMPLA MEDICARE PTAN
COC810212OtherMEDICARE GROUP NUMBER
CO810212OtherMEDICARE GROUP PTAN
CO54025079OtherMEDICAID GROUP NUMBER
CO54025079OtherMEDICAID GROUP NUMBER
CO98582232Medicaid