Provider Demographics
NPI:1376377077
Name:ELLIS, EMILY JEANNENE (FNP)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:JEANNENE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 COUNTY ROAD 132
Mailing Address - Street 2:
Mailing Address - City:COMANCHE
Mailing Address - State:TX
Mailing Address - Zip Code:76442-4496
Mailing Address - Country:US
Mailing Address - Phone:575-644-8510
Mailing Address - Fax:
Practice Address - Street 1:10201 HIGHWAY 16
Practice Address - Street 2:
Practice Address - City:COMANCHE
Practice Address - State:TX
Practice Address - Zip Code:76442-4462
Practice Address - Country:US
Practice Address - Phone:254-879-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-27
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1167481363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily