MEDICARE: MS. ETHEL J ELLIS MSN,RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	0001267842	VA

General Provider Information

NPI Number	:	1679420988
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ETHEL J ELLIS MSN,RN

Provider Business Mailing Address
First Line	:	1045B ELM ST
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28303-4068
Country	:	US
Telephone Number	:	609-532-8400
Fax Number	:

Provider Business Practice Location Address
First Line	:	1045B ELM ST
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28303-4068
Country	:	US
Telephone Number	:	609-532-8400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2026
Last Update Date	:	03/16/2026

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