Healthcare Provider Details

I. General information

NPI: 1780086710
Provider Name (Legal Business Name): ELLISON BETH DART PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2014
Last Update Date: 09/12/2022
Certification Date: 09/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10027 US 70 BUSINESS HWY W STE C
CLAYTON NC
27520-2115
US

IV. Provider business mailing address

2885 OLD US 70 HWY W LOT 33
CLAYTON NC
27520-6562
US

V. Phone/Fax

Practice location:
  • Phone: 919-424-0062
  • Fax: 919-704-3674
Mailing address:
  • Phone: 919-817-3373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5014036
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number228772
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: