Provider Demographics
NPI:1063005874
Name:ELLIS, NAKESIA (MSN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:NAKESIA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MSN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2969 CURRAN DR N
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4121
Mailing Address - Country:US
Mailing Address - Phone:601-200-3100
Mailing Address - Fax:
Practice Address - Street 1:2969 CURRAN DR N
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4121
Practice Address - Country:US
Practice Address - Phone:601-200-3100
Practice Address - Fax:601-200-8846
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-12
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904456363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05323277Medicaid