Provider Demographics
NPI:1720385412
Name:ELLIS, SARAH E (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SARAH
Middle Name:E
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 1:502 E GENERAL STEWART WAY
Mailing Address - Street 2:STE A
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-2643
Mailing Address - Country:US
Mailing Address - Phone:912-876-3552
Mailing Address - Fax:912-876-3556
Practice Address - Street 1:502 E GENERAL STEWART WAY STE A
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313
Practice Address - Country:US
Practice Address - Phone:912-368-1966
Practice Address - Fax:912-368-1966
Is Sole Proprietor?:No
Enumeration Date:2011-02-16
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN256687363LF0000X
FL9247399363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003182987BMedicaid
GA003182987AMedicaid