Provider Demographics
NPI:1649468406
Name:PETERSON, ELLEN DAVIS (CNS)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:DAVIS
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:C
Other - Last Name:WALTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNS
Mailing Address - Street 1:6500 NORTH MOPAC EXPRESSWAY
Mailing Address - Street 2:BUILDING 3, SUITE 200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731
Mailing Address - Country:US
Mailing Address - Phone:512-458-8400
Mailing Address - Fax:512-458-8593
Practice Address - Street 1:6500 NORTH MOPAC EXPRESSWAY
Practice Address - Street 2:BUILDING 3, SUITE 200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731
Practice Address - Country:US
Practice Address - Phone:512-458-8400
Practice Address - Fax:512-458-8593
Is Sole Proprietor?:No
Enumeration Date:2007-10-05
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2007004651364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L2435Medicare PIN
TXTXB118890Medicare PIN