Provider Demographics
NPI:1982845939
Name:ELLIS, ELIZABETH KAY (APN)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:KAY
Last Name:ELLIS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 W PINE ST STE A
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:AR
Mailing Address - Zip Code:72150-2443
Mailing Address - Country:US
Mailing Address - Phone:870-942-1301
Mailing Address - Fax:870-942-1305
Practice Address - Street 1:651 HERITAGE DR
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:AR
Practice Address - Zip Code:72150-5000
Practice Address - Country:US
Practice Address - Phone:870-942-1301
Practice Address - Fax:870-942-1305
Is Sole Proprietor?:No
Enumeration Date:2009-03-19
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03208 ANP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR190499758Medicaid
ARAO3208ANPOtherANP LICENSE
AR190499758Medicaid