1174397194 NPI number — STEPHEN ELLIS APNP

Table of content: STEPHEN ELLIS APNP (NPI 1174397194)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174397194 NPI number — STEPHEN ELLIS APNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIS
Provider First Name:
STEPHEN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APNP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174397194
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
157 N 123RD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUWATOSA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53226-3809
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-271-6371
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5000 WEST CHAMBERS ST
Provider Second Line Business Practice Location Address:
7TH FL/7 WEST
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53210-1645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-445-6520
Provider Business Practice Location Address Fax Number:
414-445-6875
Provider Enumeration Date:
11/09/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  15670-33 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 163WE0003X , with the licence number: 164543-30 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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