Provider Demographics
NPI:1396104907
Name:ELLIS, YASMIN (LPN)
Entity type:Individual
Prefix:MRS
First Name:YASMIN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:YASMIN
Other - Middle Name:
Other - Last Name:BURRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:1157 LAKEWALK DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-2442
Mailing Address - Country:US
Mailing Address - Phone:615-587-2216
Mailing Address - Fax:
Practice Address - Street 1:620 GALLATIN PIKE S
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-4013
Practice Address - Country:US
Practice Address - Phone:615-460-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-11
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000078268164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse