Provider Demographics
NPI:1457984361
Name:ELLIS, KYLIE ALYSSA (APRN)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:ALYSSA
Last Name:ELLIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KYLIE
Other - Middle Name:ALYSSA
Other - Last Name:KULLMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:795 POPLAR RD STE 400
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-2590
Mailing Address - Country:US
Mailing Address - Phone:770-716-0051
Mailing Address - Fax:
Practice Address - Street 1:795 POPLAR RD STE 400
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2590
Practice Address - Country:US
Practice Address - Phone:770-716-0051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-19
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN239284163W00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse