Provider Demographics
NPI:1285720250
Name:NELLIS, STACIE LYNN (FNP)
Entity type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:LYNN
Last Name:NELLIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80495 US HIGHWAY 111
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-6534
Mailing Address - Country:US
Mailing Address - Phone:760-347-2887
Mailing Address - Fax:
Practice Address - Street 1:80495 US HIGHWAY 111
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-6534
Practice Address - Country:US
Practice Address - Phone:760-347-2887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP16463363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1285720250Medicaid