Provider Demographics
NPI:1518470830
Name:ELLISOR, SARA BETH (FNP)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:BETH
Last Name:ELLISOR
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 HARDY LN
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77320-1872
Mailing Address - Country:US
Mailing Address - Phone:936-537-7749
Mailing Address - Fax:
Practice Address - Street 1:521 INTERSTATE 45 S STE 2B
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77340-5649
Practice Address - Country:US
Practice Address - Phone:936-436-9098
Practice Address - Fax:936-439-9098
Is Sole Proprietor?:No
Enumeration Date:2017-11-08
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP135774363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX425200901Medicaid