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General NPI Number Information
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NPI Number | 1205655594
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Entity Type | Individual
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Provider Name | MADELYNE ELLIS FNP
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Gender | Female
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Dates
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Enumeration Date | 10/04/2024
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Last Update Date | 10/04/2024
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Provider Practice Location Address
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Address Line | 1159 WALTER TAYLOR RD
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City | FRIENDSHIP
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State | TN
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Zip | 38034-3449
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Country | US
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Telephone | 931-787-4062
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Fax |
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Provider Business Mailing Address
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Address Line | 60 PHYSICIANS LN
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City | SOUTHAVEN
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State | MS
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Zip | 38671-6122
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 35673
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License Number State | TN
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