Provider Demographics
NPI:1013466697
Name:ELLSBERRY, TASHA (APRN, FNP, PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:TASHA
Middle Name:
Last Name:ELLSBERRY
Suffix:
Gender:F
Credentials:APRN, FNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 W 20TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32254-1703
Mailing Address - Country:US
Mailing Address - Phone:904-930-9215
Mailing Address - Fax:941-641-7089
Practice Address - Street 1:13453 N MAIN ST STE 104
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-2773
Practice Address - Country:US
Practice Address - Phone:904-773-4390
Practice Address - Fax:941-641-7089
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-24
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9344392163WG0000X, 363LP0808X, 363LP0808X
FLARNP9344392363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily