Basic Information
| Provider Information | |||||||||
| NPI: | 1811052145 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLMORE | ||||||||
| FirstName: | JOAN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 EAST JEFFERSON STREET PPQA MEDICARE COMPLIANCE UNI | ||||||||
| Address2: | KAISER PERMANENTE MID ATLANTIC PERMANENTE MEDICAL GROUP | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208524908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018166660 | ||||||||
| FaxNumber: | 3018166308 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 SAM PERRY BLVD | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224018420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407413716 | ||||||||
| FaxNumber: | 5407411096 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 01/25/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 0001073375 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.