Provider Demographics
NPI:1649880477
Name:ELLIS, JOSIE
Entity type:Individual
Prefix:
First Name:JOSIE
Middle Name:
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 1:14722 COUNTY ROAD 4188 S
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TX
Mailing Address - Zip Code:75654-6344
Mailing Address - Country:US
Mailing Address - Phone:903-646-6250
Mailing Address - Fax:
Practice Address - Street 1:14722 COUNTY ROAD 4188 S
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TX
Practice Address - Zip Code:75654-6344
Practice Address - Country:US
Practice Address - Phone:903-646-6250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX351409164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse