Provider Demographics
NPI:1528149531
Name:ELLIS, DANIELLA S (FNP)
Entity type:Individual
Prefix:
First Name:DANIELLA
Middle Name:S
Last Name:ELLIS
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:PO BOX 789
Mailing Address - Street 2:
Mailing Address - City:TUNICA
Mailing Address - State:MS
Mailing Address - Zip Code:38676-0789
Mailing Address - Country:US
Mailing Address - Phone:662-357-0012
Mailing Address - Fax:662-357-0021
Practice Address - Street 1:11273 HIGHWAY 61 N
Practice Address - Street 2:
Practice Address - City:ROBINSONVILLE
Practice Address - State:MS
Practice Address - Zip Code:38664-9705
Practice Address - Country:US
Practice Address - Phone:662-357-0012
Practice Address - Fax:662-357-0021
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR87-3851363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1528149531Medicare PIN