Provider Demographics
NPI:1568726289
Name:ELLIS, TONYA L (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:TONYA
Middle Name:L
Last Name:ELLIS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 MAIN ST
Mailing Address - Street 2:STE C
Mailing Address - City:TRACY CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37387-4020
Mailing Address - Country:US
Mailing Address - Phone:931-592-9199
Mailing Address - Fax:
Practice Address - Street 1:740 MAIN ST
Practice Address - Street 2:STE C
Practice Address - City:TRACY CITY
Practice Address - State:TN
Practice Address - Zip Code:37387-4020
Practice Address - Country:US
Practice Address - Phone:931-592-9199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-27
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16863261QM0801X, 261QH0100X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service