Provider Demographics
NPI:1245232297
Name:ELLIS, SUNDIE WRIGHT (APRN, BC, FNP)
Entity Type:Individual
Prefix:MS
First Name:SUNDIE
Middle Name:WRIGHT
Last Name:ELLIS
Suffix:
Gender:F
Credentials:APRN, BC, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10717 LIPAN TRL
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76108-6924
Mailing Address - Country:US
Mailing Address - Phone:817-244-1592
Mailing Address - Fax:
Practice Address - Street 1:10717 LIPAN TRL
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76108-6924
Practice Address - Country:US
Practice Address - Phone:817-244-1592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX667088363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP34000Medicare UPIN
TX86N138Medicare ID - Type Unspecified