Provider Demographics
NPI:1811565120
Name:ELLIS, CHANDRA (RN)
Entity Type:Individual
Prefix:
First Name:CHANDRA
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 1:716 MUD LAKE TRL
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76120-2037
Mailing Address - Country:US
Mailing Address - Phone:682-564-2588
Mailing Address - Fax:
Practice Address - Street 1:716 MUD LAKE TRL
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76120-2037
Practice Address - Country:US
Practice Address - Phone:682-564-2588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-14
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX644695163W00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No163W00000XNursing Service ProvidersRegistered Nurse