Provider Demographics
NPI:1801227368
Name:ELLIS, TRACI LYNNETTE (APRN)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:LYNNETTE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:LYNNETTE
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP-C
Mailing Address - Street 1:1313 S ST STE A
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:NE
Mailing Address - Zip Code:69336-2563
Mailing Address - Country:US
Mailing Address - Phone:308-262-1755
Mailing Address - Fax:308-262-0765
Practice Address - Street 1:1313 S ST STE A
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:NE
Practice Address - Zip Code:69336-2563
Practice Address - Country:US
Practice Address - Phone:308-262-1755
Practice Address - Fax:308-262-0765
Is Sole Proprietor?:No
Enumeration Date:2013-12-10
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE111534363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily