Individual
JACQUELINE ELLIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
3333 EVERGREEN DR NE, GRAND RAPIDS, MI 49525-9493
(616) 364-4200
(616) 364-7347
Mailing address
3333 EVERGREEN DR NE, GRAND RAPIDS, MI 49525-9493
(616) 364-4200
(616) 364-7347
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
4704360147
MI
367500000X
Certified Registered Nurse Anesthetist
Primary
4704360147
MI
Other
Enumeration date
09/06/2017
Last updated
01/04/2023
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