Healthcare Provider Details

I. General information

NPI: 1144705849
Provider Name (Legal Business Name): AMBER NICOLE ELLIS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMBER PROSSER

II. Dates (important events)

Enumeration Date: 09/27/2018
Last Update Date: 06/04/2020
Certification Date: 06/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 S 4TH ST
CLINTON OK
73601-2309
US

IV. Provider business mailing address

1218 E HIGHLINE LN
MUSTANG OK
73064-6406
US

V. Phone/Fax

Practice location:
  • Phone: 405-376-9980
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number91331
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF10171219
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: