Provider Demographics
NPI:1588795587
Name:ELLIS, VICTORIA FELTY
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:FELTY
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
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 630
Mailing Address - Street 2:
Mailing Address - City:BLOUNTVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37617-0630
Mailing Address - Country:US
Mailing Address - Phone:423-279-2777
Mailing Address - Fax:423-279-2797
Practice Address - Street 1:154 BLOUNTVILLE BYPASS
Practice Address - Street 2:
Practice Address - City:BLOUNTVILLE
Practice Address - State:TN
Practice Address - Zip Code:37617
Practice Address - Country:US
Practice Address - Phone:423-279-2777
Practice Address - Fax:423-279-2797
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19260164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3170197Medicare ID - Type Unspecified3170197
TNB58933Medicare UPIN