Provider Demographics
NPI:1174502124
Name:ELLIS, LAURA (MSN)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:MS
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN
Mailing Address - Street 1:1835 SAVOY DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1072
Mailing Address - Country:US
Mailing Address - Phone:770-496-9400
Mailing Address - Fax:770-496-9495
Practice Address - Street 1:1100 JOHNSON FERRY RD NE
Practice Address - Street 2:SUITE 600
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30342-1709
Practice Address - Country:US
Practice Address - Phone:404-256-4777
Practice Address - Fax:404-256-5515
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN050577363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACA9328OtherMEDICARE GROUP-DMERC
GA000885739CMedicaid
GAP27773Medicare UPIN
GA50BBDRPMedicare PIN