Provider Demographics
NPI:1417020751
Name:MISHRA, ELLEN MARGARET (WHNP-C, FNP-C)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:MARGARET
Last Name:MISHRA
Suffix:
Gender:F
Credentials:WHNP-C, FNP-C
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:MARGARET
Other - Last Name:WEAVER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:WHNP, FNP-C
Mailing Address - Street 1:60 COMMERCE PLAZA CIR
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-7386
Mailing Address - Country:US
Mailing Address - Phone:910-521-2900
Mailing Address - Fax:910-775-9165
Practice Address - Street 1:207 E MONROE ST
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:SC
Practice Address - Zip Code:29536-2557
Practice Address - Country:US
Practice Address - Phone:843-774-4337
Practice Address - Fax:843-774-4373
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3943363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1474Medicaid
SCP00939456OtherRAILROAD MEDIARE PTAN
SCNP1474Medicaid
SCAA42534784Medicare PIN
SCAA42537981Medicare PIN
SCAA42537977Medicare PIN
SCP00939456OtherRAILROAD MEDIARE PTAN
SCAA42531850Medicare PIN