Provider Demographics
NPI:1861936049
Name:MACKINNON, ELLEN RAE (CNS-NP)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:RAE
Last Name:MACKINNON
Suffix:
Gender:F
Credentials:CNS-NP
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:RAE
Other - Last Name:MURRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:120 E HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:DRIGGS
Mailing Address - State:ID
Mailing Address - Zip Code:83422-5112
Mailing Address - Country:US
Mailing Address - Phone:208-354-6354
Mailing Address - Fax:208-354-2228
Practice Address - Street 1:120 E HOWARD ST
Practice Address - Street 2:
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422-5112
Practice Address - Country:US
Practice Address - Phone:208-354-6354
Practice Address - Fax:208-354-2228
Is Sole Proprietor?:No
Enumeration Date:2016-12-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN992817363LA2200X, 364SA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO558215YLSHMedicare PIN