Provider Demographics
NPI:1275292666
Name:SMITH, ELLESSE
Entity Type:Individual
Prefix:
First Name:ELLESSE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELLESSE
Other - Middle Name:
Other - Last Name:KIDD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:808 WALPOLE DR
Mailing Address - Street 2:
Mailing Address - City:GALLATIN
Mailing Address - State:TN
Mailing Address - Zip Code:37066-6753
Mailing Address - Country:US
Mailing Address - Phone:615-390-4733
Mailing Address - Fax:
Practice Address - Street 1:1250 ROBINSON RD
Practice Address - Street 2:
Practice Address - City:OLD HICKORY
Practice Address - State:TN
Practice Address - Zip Code:37138-3326
Practice Address - Country:US
Practice Address - Phone:615-390-4733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN30474363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner