=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104518596
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH A. ELLIS DNP, FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2023
-----------------------------------------------------
Last Update Date | 03/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2812 HARTFORD HWY STE 1
-----------------------------------------------------
City | DOTHAN
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36305-4927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-712-1170
-----------------------------------------------------
Fax | 334-460-8391
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1703 N COUNTY ROAD 67
-----------------------------------------------------
City | SKIPPERVILLE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36374-5834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-701-0224
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 1-106812
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------