Provider Demographics
NPI:1518571900
Name:ELLIS, LAWANDA NICOLE (FNP)
Entity Type:Individual
Prefix:
First Name:LAWANDA
Middle Name:NICOLE
Last Name:ELLIS
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 1:531 MS-28
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39168-5791
Mailing Address - Country:US
Mailing Address - Phone:601-785-9580
Mailing Address - Fax:
Practice Address - Street 1:531 MS-23
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:MS
Practice Address - Zip Code:39168
Practice Address - Country:US
Practice Address - Phone:601-785-9580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-02
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901770363LF0000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily