Provider Demographics
NPI:1619948569
Name:ELLIS, TERESA W (APRN)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:W
Last Name:ELLIS
Suffix:
Gender:F
Credentials:APRN
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 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:606-330-7835
Mailing Address - Fax:606-330-7825
Practice Address - Street 1:740 S LIMESTONE STE J107
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-9792
Practice Address - Country:US
Practice Address - Phone:859-323-5603
Practice Address - Fax:859-323-3704
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007458363LA2100X, 363LF0000X
VA0024087401363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100007360Medicaid