Individual
KEITH LAWRENCE ELLIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
46 ALBION ST, BRIDGEPORT, CT 06605-2602
(203) 330-6000
(203) 330-6008
Mailing address
46 ALBION ST, BRIDGEPORT, CT 06605-2602
(203) 330-6000
(203) 330-6008
Taxonomy
Speciality
Code
Description
License number
State
363LP0200X
Pediatric Nurse Practitioner
Primary
5501
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
004236136
—
CT
Enumeration date
09/03/2013
Last updated
09/12/2022
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