Healthcare Provider Details

I. General information

NPI: 1093430225
Provider Name (Legal Business Name): DESTINEY N ELLIS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2022
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MCGOWAN CT
HOT SPRINGS AR
71913-6452
US

IV. Provider business mailing address

330 BURCHWOOD BAY RD APT E38
HOT SPRINGS AR
71913-7180
US

V. Phone/Fax

Practice location:
  • Phone: 501-525-9675
  • Fax:
Mailing address:
  • Phone: 501-276-4075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number222059
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: