Provider Demographics
NPI:1639995699
Name:ELLIS, STEPHANIE MARIE (ARNP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARIE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8220 SW 29TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-2425
Mailing Address - Country:US
Mailing Address - Phone:786-449-0629
Mailing Address - Fax:
Practice Address - Street 1:9410 SW 77TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-7903
Practice Address - Country:US
Practice Address - Phone:786-701-8106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11036590363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily