Provider Demographics
NPI:1093430225
Name:ELLIS, DESTINEY N (FNP-C)
Entity Type:Individual
Prefix:
First Name:DESTINEY
Middle Name:N
Last Name:ELLIS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 BURCHWOOD BAY RD APT E38
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-7180
Mailing Address - Country:US
Mailing Address - Phone:501-276-4075
Mailing Address - Fax:
Practice Address - Street 1:100 MCGOWAN CT
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-6452
Practice Address - Country:US
Practice Address - Phone:501-525-9675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-10
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR222059363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily