Provider Demographics
NPI:1730550492
Name:ELLIS, COURTNEY DYAN (NP-C)
Entity type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:DYAN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5172 LEAVITT RD
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-2384
Mailing Address - Country:US
Mailing Address - Phone:440-282-7420
Mailing Address - Fax:
Practice Address - Street 1:5172 LEAVITT RD
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-2384
Practice Address - Country:US
Practice Address - Phone:440-282-7420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.18102-NP363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care