Healthcare Provider Details

I. General information

NPI: 1376377077
Provider Name (Legal Business Name): EMILY JEANNENE ELLIS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2024
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10201 HIGHWAY 16
COMANCHE TX
76442-4462
US

IV. Provider business mailing address

350 COUNTY ROAD 132
COMANCHE TX
76442-4496
US

V. Phone/Fax

Practice location:
  • Phone: 254-879-4900
  • Fax:
Mailing address:
  • Phone: 575-644-8510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1167481
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: