Provider Demographics
NPI:1225802770
Name:ELLISOR, AMANDA (FNP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ELLISOR
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:HERBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1602 E HOUSTON ST STE C
Mailing Address - Street 2:
Mailing Address - City:BEEVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78102-5335
Mailing Address - Country:US
Mailing Address - Phone:361-354-2900
Mailing Address - Fax:
Practice Address - Street 1:1602 E HOUSTON ST STE C
Practice Address - Street 2:
Practice Address - City:BEEVILLE
Practice Address - State:TX
Practice Address - Zip Code:78102-5335
Practice Address - Country:US
Practice Address - Phone:361-354-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-14
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX858478163WE0003X
TX1153063363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency