Provider Demographics
NPI:1619607447
Name:ELLIS, HANNAH NICOLE
Entity Type:Individual
Prefix:
First Name:HANNAH
Middle Name:NICOLE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 575
Mailing Address - Street 2:
Mailing Address - City:DIERKS
Mailing Address - State:AR
Mailing Address - Zip Code:71833-0575
Mailing Address - Country:US
Mailing Address - Phone:870-784-0884
Mailing Address - Fax:870-825-2060
Practice Address - Street 1:1124 MAIN AVE
Practice Address - Street 2:
Practice Address - City:DIERKS
Practice Address - State:AR
Practice Address - Zip Code:71833-9421
Practice Address - Country:US
Practice Address - Phone:870-784-0884
Practice Address - Fax:870-825-2060
Is Sole Proprietor?:No
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator