Provider Demographics
NPI:1083060578
Name:ELLIS, NATASHA (NP)
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 CANTON RD NE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-7271
Mailing Address - Country:US
Mailing Address - Phone:770-428-4486
Mailing Address - Fax:
Practice Address - Street 1:702 CANTON RD NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7271
Practice Address - Country:US
Practice Address - Phone:770-428-4486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-13
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN189933363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily