Provider Demographics
NPI:1750608287
Name:ELLIS, STACY (CFNP)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8060 WOLF RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-1727
Mailing Address - Country:US
Mailing Address - Phone:901-271-1000
Mailing Address - Fax:901-271-4187
Practice Address - Street 1:8060 WOLF RIVER BLVD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1727
Practice Address - Country:US
Practice Address - Phone:901-271-1000
Practice Address - Fax:901-271-4187
Is Sole Proprietor?:No
Enumeration Date:2010-04-23
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR884850363L00000X
TN176698363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN17698OtherTN APN