Provider Demographics
NPI:1518455716
Name:ELLIS, GWYNDOLYN (RN, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:GWYNDOLYN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RN, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 EAGLEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-1414
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:650 JOEL DR
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5318
Practice Address - Country:US
Practice Address - Phone:270-798-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX922427163W00000X
TXAT72182255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No163W00000XNursing Service ProvidersRegistered Nurse
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer