Healthcare Provider Details

I. General information

NPI: 1275614489
Provider Name (Legal Business Name): DONNA ELLIS OGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 11/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

371 NC HWY 65 STE 204
WENTWORTH NC
27320
US

IV. Provider business mailing address

PO BOX 204
WENTWORTH NC
27375-0204
US

V. Phone/Fax

Practice location:
  • Phone: 336-342-8140
  • Fax: 336-342-8128
Mailing address:
  • Phone: 336-342-8140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number800002
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number800002
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number800002
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: