Provider Demographics
NPI:1649921123
Name:ELLIS, SANDRA (FNP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
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 1:120 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CIRCLEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43113-1654
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 UHRIG ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OH
Practice Address - Zip Code:45133-1427
Practice Address - Country:US
Practice Address - Phone:740-529-2125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-15
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH296873163WP0808X
KY3017937363L00000X
OH0031591363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health