Healthcare Provider Details

I. General information

NPI: 1528149531
Provider Name (Legal Business Name): DANIELLA S ELLIS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 08/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11273 HIGHWAY 61 N
ROBINSONVILLE MS
38664-9705
US

IV. Provider business mailing address

PO BOX 789
TUNICA MS
38676-0789
US

V. Phone/Fax

Practice location:
  • Phone: 662-357-0012
  • Fax: 662-357-0021
Mailing address:
  • Phone: 662-357-0012
  • Fax: 662-357-0021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR87-3851
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: