Provider Demographics
NPI:1831439538
Name:ELLIS, CYNTHIA R
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:R
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 OLD HICKORY BLVD STE G
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2911
Mailing Address - Country:US
Mailing Address - Phone:731-660-6402
Mailing Address - Fax:731-664-6603
Practice Address - Street 1:621 OLD HICKORY BLVD STE G
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2911
Practice Address - Country:US
Practice Address - Phone:731-660-6402
Practice Address - Fax:731-664-6603
Is Sole Proprietor?:No
Enumeration Date:2013-02-18
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000083514163W00000X
TN0000016607363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse