1437766201 NPI number — DR. JACQUELINE ANN ELLISON DNP, ARNP, FNP-C

Table of content: DR. JACQUELINE ANN ELLISON DNP, ARNP, FNP-C (NPI 1437766201)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437766201 NPI number — DR. JACQUELINE ANN ELLISON DNP, ARNP, FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLISON
Provider First Name:
JACQUELINE
Provider Middle Name:
ANN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DNP, ARNP, FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRUNGARDT
Provider Other First Name:
JACQUELINE
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1437766201
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2015 W 5TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STORM LAKE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50588-3000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-732-6650
Provider Business Mailing Address Fax Number:
712-732-6632

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2015 W 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STORM LAKE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50588-3000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-732-6650
Provider Business Practice Location Address Fax Number:
712-732-6632
Provider Enumeration Date:
09/25/2020

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:  A160841 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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