Provider Demographics
NPI:1164938544
Name:ELLIS, SHANA M (CRNP)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:M
Last Name:ELLIS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:SHANA
Other - Middle Name:M
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:5086 AL HIGHWAY 73
Mailing Address - Street 2:
Mailing Address - City:BRYANT
Mailing Address - State:AL
Mailing Address - Zip Code:35958-4316
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29810 AL HIGHWAY 71
Practice Address - Street 2:
Practice Address - City:BRYANT
Practice Address - State:AL
Practice Address - Zip Code:35958-5240
Practice Address - Country:US
Practice Address - Phone:256-597-2135
Practice Address - Fax:256-597-4115
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-145902363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily