Provider Demographics
NPI:1013013721
Name:ELLISON, NICOLE M (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:ELLISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 SANDWELL PL
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77389-2038
Mailing Address - Country:US
Mailing Address - Phone:501-837-3680
Mailing Address - Fax:
Practice Address - Street 1:1100 W BLUFF ST
Practice Address - Street 2:
Practice Address - City:WOODVILLE
Practice Address - State:TX
Practice Address - Zip Code:75979-4738
Practice Address - Country:US
Practice Address - Phone:409-283-8141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81826207Q00000X
TXN2485207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine