Healthcare Provider Details

I. General information

NPI: 1881728723
Provider Name (Legal Business Name): CONSTANCE ELIZABETH ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 01/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 E GREENWOOD
HOPE AR
71854
US

IV. Provider business mailing address

2904 ARKANSAS BLVD
TEXARKANA AR
71854-2536
US

V. Phone/Fax

Practice location:
  • Phone: 870-777-9800
  • Fax: 870-777-9811
Mailing address:
  • Phone: 870-773-4655
  • Fax: 870-772-4650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberR092493
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: