Provider Demographics
NPI:1023531340
Name:ELLIS, KIMBERLY Y
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:Y
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7365 GRANVILLE DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-4647
Mailing Address - Country:US
Mailing Address - Phone:469-657-9165
Mailing Address - Fax:
Practice Address - Street 1:7365 GRANVILLE DR
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-4647
Practice Address - Country:US
Practice Address - Phone:469-657-9165
Practice Address - Fax:469-657-9165
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-18
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherNONE