Healthcare Provider Details

I. General information

NPI: 1508318494
Provider Name (Legal Business Name): KEISHA ELLIS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2016
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7649 W COLONIAL DR STE 115
ORLANDO FL
32818-7423
US

IV. Provider business mailing address

6101 BLUE LAGOON DR STE 200
MIAMI FL
33126-3168
US

V. Phone/Fax

Practice location:
  • Phone: 407-522-2080
  • Fax: 833-963-0115
Mailing address:
  • Phone: 844-630-0700
  • Fax: 877-374-1924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP-03387
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9281197
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP03387
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: