Provider Demographics
NPI:1194346759
Name:ELLIS, KELLY NICOLE (RN)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:NICOLE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13819 COUNTY ROAD 1131
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:TX
Mailing Address - Zip Code:75762-2419
Mailing Address - Country:US
Mailing Address - Phone:903-952-6368
Mailing Address - Fax:
Practice Address - Street 1:13819 COUNTY ROAD 1131
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:TX
Practice Address - Zip Code:75762-2419
Practice Address - Country:US
Practice Address - Phone:903-952-6368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX855575163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse