Healthcare Provider Details

I. General information

NPI: 1487138608
Provider Name (Legal Business Name): SHONTA ELLISON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2018
Last Update Date: 09/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 LAKE VALLEY DR
MAUMELLE AR
72113-5939
US

IV. Provider business mailing address

130 LAKE VALLEY DR
MAUMELLE AR
72113-5939
US

V. Phone/Fax

Practice location:
  • Phone: 501-766-1884
  • Fax:
Mailing address:
  • Phone: 501-766-1884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License NumberS002325
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License NumberS002325
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: