Provider Demographics
NPI:1295792067
Name:ELLIS, COLETTE SUZANNE (CRNA)
Entity type:Individual
Prefix:
First Name:COLETTE
Middle Name:SUZANNE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1671 N CLYDE MORRIS BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5590
Mailing Address - Country:US
Mailing Address - Phone:386-274-2977
Mailing Address - Fax:386-274-2997
Practice Address - Street 1:1545 HAND AVE STE A1
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174
Practice Address - Country:US
Practice Address - Phone:386-274-2977
Practice Address - Fax:386-274-2997
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2156367500000X
FLARNP9168266367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004480400Medicaid
SCQ33823Medicare PIN
SCQ33823Medicare UPIN