Provider Demographics
NPI:1194349308
Name:ELLIS, BETHANY LAQUELL (FNP)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:LAQUELL
Last Name:ELLIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:LAQUELL
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1001 N FEDERAL HWY STE 341
Mailing Address - Street 2:
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-2404
Mailing Address - Country:US
Mailing Address - Phone:754-444-9173
Mailing Address - Fax:786-221-3179
Practice Address - Street 1:1001 N FEDERAL HWY STE 341
Practice Address - Street 2:
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-2404
Practice Address - Country:US
Practice Address - Phone:754-444-9173
Practice Address - Fax:786-221-3179
Is Sole Proprietor?:No
Enumeration Date:2020-06-03
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11007347363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily