Provider Demographics
NPI:1922778943
Name:ELLIS, TRACEY L (APRN)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:L
Last Name:ELLIS
Suffix:
Gender:F
Credentials:APRN
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 650859
Mailing Address - Street 2:DEPT 710
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-1668
Mailing Address - Country:US
Mailing Address - Phone:409-747-6240
Mailing Address - Fax:
Practice Address - Street 1:701 E DAVIS ST STE A
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77301-3102
Practice Address - Country:US
Practice Address - Phone:936-525-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-20
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1054414363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics