Provider Demographics
NPI:1194301242
Name:ELLIS, AUTUMN DENISE (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:AUTUMN
Middle Name:DENISE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3189 GARRETT BALL RD
Mailing Address - Street 2:
Mailing Address - City:GATES
Mailing Address - State:TN
Mailing Address - Zip Code:38037-5206
Mailing Address - Country:US
Mailing Address - Phone:731-694-2872
Mailing Address - Fax:
Practice Address - Street 1:320 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:HALLS
Practice Address - State:TN
Practice Address - Zip Code:38040-1510
Practice Address - Country:US
Practice Address - Phone:731-836-9303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN29129363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily