Provider Demographics
NPI:1245018605
Name:ELLIS, TANARA NICOLE
Entity type:Individual
Prefix:
First Name:TANARA
Middle Name:NICOLE
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 1:10716 PRAIRIE LN
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73162-4046
Mailing Address - Country:US
Mailing Address - Phone:405-208-2308
Mailing Address - Fax:
Practice Address - Street 1:3917 SPRING GROVE AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45223-3302
Practice Address - Country:US
Practice Address - Phone:513-357-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH034436911835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist