Provider Demographics
NPI:1760550990
Name:THOMAS ELLIS, DONNA A (CFNP)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:A
Last Name:THOMAS ELLIS
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:A
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CFNP
Mailing Address - Street 1:PO BOX 321359
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-1359
Mailing Address - Country:US
Mailing Address - Phone:601-933-5417
Mailing Address - Fax:601-936-1336
Practice Address - Street 1:1040 N FLOWOOD DR STE 100
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9789
Practice Address - Country:US
Practice Address - Phone:601-933-5417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS602612363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05457378Medicaid