Provider Demographics
NPI:1679700470
Name:ELLISON, KAREN A
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:A
Last Name:ELLISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 W COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80905-1518
Mailing Address - Country:US
Mailing Address - Phone:719-219-3876
Mailing Address - Fax:719-219-3883
Practice Address - Street 1:910 W COLORADO AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905-1518
Practice Address - Country:US
Practice Address - Phone:719-219-3876
Practice Address - Fax:719-219-3883
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6646174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist