Provider Demographics
NPI:1114909538
Name:ELLINGTON, BETTY JO (DNP, APRN, FNP-BC)
Entity Type:Individual
Prefix:DR
First Name:BETTY JO
Middle Name:
Last Name:ELLINGTON
Suffix:
Gender:F
Credentials:DNP, APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1413 RUSSELL AVE
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37760-2562
Mailing Address - Country:US
Mailing Address - Phone:865-471-5525
Mailing Address - Fax:
Practice Address - Street 1:1413 RUSSELL AVE
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-2562
Practice Address - Country:US
Practice Address - Phone:865-471-5525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-20
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000006086363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN200382097OtherTAX I.D.
TN1508879719OtherGROUP NPI
TN4075540OtherBLUE CROSS BLUE SHIELD
TN4155963OtherBLUE CROSS BLUE SHIELD
TN4155963OtherBLUE CROSS BLUE SHIELD
TN3723200Medicare ID - Type UnspecifiedMEDICARE GROUP
TN4075540OtherBLUE CROSS BLUE SHIELD