Provider Demographics
NPI:1174769830
Name:ELLIS, NICHOLE KRISTINE (DO)
Entity type:Individual
Prefix:DR
First Name:NICHOLE
Middle Name:KRISTINE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 S HOWELL ST
Mailing Address - Street 2:
Mailing Address - City:HILLSDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49242-2069
Mailing Address - Country:US
Mailing Address - Phone:517-437-5385
Mailing Address - Fax:
Practice Address - Street 1:187 S HOWELL ST
Practice Address - Street 2:
Practice Address - City:HILLSDALE
Practice Address - State:MI
Practice Address - Zip Code:49242-2069
Practice Address - Country:US
Practice Address - Phone:517-437-5385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-31
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5101018596208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program