Provider Demographics
NPI:1225802770
Name:ELLISOR, AMANDA (RN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ELLISOR
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:HERBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:500 E HOUSTON ST
Mailing Address - Street 2:
Mailing Address - City:BEEVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78102-4941
Mailing Address - Country:US
Mailing Address - Phone:361-542-4355
Mailing Address - Fax:361-578-0221
Practice Address - Street 1:500 E HOUSTON ST
Practice Address - Street 2:
Practice Address - City:BEEVILLE
Practice Address - State:TX
Practice Address - Zip Code:78102-4941
Practice Address - Country:US
Practice Address - Phone:361-542-4355
Practice Address - Fax:361-578-0221
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-14
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX858478163WE0003X
TX1153063363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency