Provider Demographics
NPI:1700125663
Name:ELLIS, MICHELLE LORRAINE (NP)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:LORRAINE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LORRAINE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:3701 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113-3611
Mailing Address - Country:US
Mailing Address - Phone:303-360-6276
Mailing Address - Fax:303-761-2787
Practice Address - Street 1:15501 E 13TH AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80011-7203
Practice Address - Country:US
Practice Address - Phone:303-360-6276
Practice Address - Fax:303-343-1006
Is Sole Proprietor?:No
Enumeration Date:2013-02-12
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0062218163WW0101X
COAPN.0990405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO65280555Medicaid
CO016313OtherKAISER COMMERCIAL NUMBER
CO298916YTUOMedicare PIN
CO65280555Medicaid