Provider Demographics
NPI:1730398546
Name:ELLISON, JOHN KENNY (RN)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:KENNY
Last Name:ELLISON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12516 CRESTLINE AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-3616
Mailing Address - Country:US
Mailing Address - Phone:505-323-9170
Mailing Address - Fax:
Practice Address - Street 1:12516 CRESTLINE AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-3616
Practice Address - Country:US
Practice Address - Phone:505-323-9170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR21266163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency