Healthcare Provider Details

I. General information

NPI: 1922778943
Provider Name (Legal Business Name): TRACEY L ELLIS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2021
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 E DAVIS ST STE A
CONROE TX
77301-3102
US

IV. Provider business mailing address

PO BOX 650859 DEPT 710
DALLAS TX
75265-1668
US

V. Phone/Fax

Practice location:
  • Phone: 936-525-2800
  • Fax:
Mailing address:
  • Phone: 409-747-6240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number1054414
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: