Provider Demographics
NPI:1275614489
Name:ELLIS, DONNA (OGNP)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:OGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 204
Mailing Address - Street 2:
Mailing Address - City:WENTWORTH
Mailing Address - State:NC
Mailing Address - Zip Code:27375-0204
Mailing Address - Country:US
Mailing Address - Phone:336-342-8140
Mailing Address - Fax:
Practice Address - Street 1:371 NC HWY 65
Practice Address - Street 2:STE 204
Practice Address - City:WENTWORTH
Practice Address - State:NC
Practice Address - Zip Code:27320
Practice Address - Country:US
Practice Address - Phone:336-342-8140
Practice Address - Fax:336-342-8128
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC800002363LX0001X, 363L00000X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC21258OtherCERTIFICATION
NC800002OtherLICENSE