Provider Demographics
NPI:1437935251
Name:ELLIS, MONICA NICOLE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:NICOLE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 WESLEY AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-1000
Mailing Address - Country:US
Mailing Address - Phone:769-777-1411
Mailing Address - Fax:
Practice Address - Street 1:402 WESLEY AVE STE 200
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1000
Practice Address - Country:US
Practice Address - Phone:601-835-5951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-06
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905990363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health