Provider Demographics
NPI:1104518596
Name:ELLIS, ELIZABETH A (DNP, FNP-C)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DNP, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 N COUNTY ROAD 67
Mailing Address - Street 2:
Mailing Address - City:SKIPPERVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36374-5834
Mailing Address - Country:US
Mailing Address - Phone:334-701-0224
Mailing Address - Fax:
Practice Address - Street 1:2812 HARTFORD HWY STE 1
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-4927
Practice Address - Country:US
Practice Address - Phone:334-712-1170
Practice Address - Fax:334-460-8391
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-23
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-106812363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily