Healthcare Provider Details

I. General information

NPI: 1093679524
Provider Name (Legal Business Name): MICHELLE LYNN ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 TATE BLVD SE STE 182
HICKORY NC
28602-4042
US

IV. Provider business mailing address

915 TATE BLVD SE STE 182
HICKORY NC
28602-4042
US

V. Phone/Fax

Practice location:
  • Phone: 828-569-2880
  • Fax: 828-569-1565
Mailing address:
  • Phone: 828-569-2880
  • Fax: 828-569-1565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF11250688
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberF11250688
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: