Provider Demographics
NPI:1740450642
Name:ELLENA, PHYLLIS JEAN (ADVANCED PRACTICE RN)
Entity type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:JEAN
Last Name:ELLENA
Suffix:
Gender:F
Credentials:ADVANCED PRACTICE RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4026 PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78228-2311
Mailing Address - Country:US
Mailing Address - Phone:210-219-5135
Mailing Address - Fax:210-434-7039
Practice Address - Street 1:4026 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78228-2311
Practice Address - Country:US
Practice Address - Phone:210-219-5135
Practice Address - Fax:210-434-7039
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-06
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX439625364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult