Healthcare Provider Details

I. General information

NPI: 1275551723
Provider Name (Legal Business Name): ANN ELLIS LYP APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 06/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3915 W 8TH ST
LITTLE ROCK AR
72204-2028
US

IV. Provider business mailing address

2 POYDRAS DR
LITTLE ROCK AR
72211-2127
US

V. Phone/Fax

Practice location:
  • Phone: 501-280-3342
  • Fax: 501-280-3144
Mailing address:
  • Phone: 501-280-3342
  • Fax: 501-280-3144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberR31695
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberA001073
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: