Provider Demographics
NPI:1043477078
Name:ELLIS, KYNDRA LENEE (RN, NNP)
Entity Type:Individual
Prefix:MRS
First Name:KYNDRA
Middle Name:LENEE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RN, NNP
Other - Prefix:
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Mailing Address - Street 1:443 GRESHAM DR
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7716
Mailing Address - Country:US
Mailing Address - Phone:678-756-1465
Mailing Address - Fax:678-756-1465
Practice Address - Street 1:443 GRESHAM DR
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7716
Practice Address - Country:US
Practice Address - Phone:678-756-1465
Practice Address - Fax:678-756-1465
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA154735163W00000X
GARN154735363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No163W00000XNursing Service ProvidersRegistered Nurse