Provider Demographics
NPI:1770007171
Name:ELLIS, TAMI (RN)
Entity Type:Individual
Prefix:
First Name:TAMI
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 EDGEDALE DR
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-2908
Mailing Address - Country:US
Mailing Address - Phone:336-689-1189
Mailing Address - Fax:
Practice Address - Street 1:2706 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-3657
Practice Address - Country:US
Practice Address - Phone:336-272-9990
Practice Address - Fax:336-574-8738
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-28
Last Update Date:2017-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC236666163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)Group - Single Specialty