Provider Demographics
NPI:1457642753
Name:ELLIS, LAUREN NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:NICOLE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:NICOLE
Other - Last Name:EGEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:214-645-3597
Mailing Address - Fax:214-645-6757
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7201
Practice Address - Country:US
Practice Address - Phone:214-645-3597
Practice Address - Fax:214-645-6757
Is Sole Proprietor?:No
Enumeration Date:2011-04-21
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
TXPA07311363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant