Provider Demographics
NPI:1750997318
Name:ELLIS, SARA J (FNP-C)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:J
Last Name:ELLIS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 STAR ST
Mailing Address - Street 2:
Mailing Address - City:POUNDING MILL
Mailing Address - State:VA
Mailing Address - Zip Code:24637-4309
Mailing Address - Country:US
Mailing Address - Phone:276-202-8995
Mailing Address - Fax:
Practice Address - Street 1:1963 2ND ST
Practice Address - Street 2:
Practice Address - City:RICHLANDS
Practice Address - State:VA
Practice Address - Zip Code:24641-2303
Practice Address - Country:US
Practice Address - Phone:276-596-9181
Practice Address - Fax:276-596-9182
Is Sole Proprietor?:No
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024180178363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily