=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316728512
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLLABORATIVENP HEALTH CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2023
-----------------------------------------------------
Last Update Date | 01/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1081 SECOND ST
-----------------------------------------------------
City | OSYKA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39657-8076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 769-264-7004
-----------------------------------------------------
Fax | 866-493-3926
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 400
-----------------------------------------------------
City | OSYKA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39657-0400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 769-264-7004
-----------------------------------------------------
Fax | 866-493-3926
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ELLEN DENISE HARRIS
-----------------------------------------------------
Credential | DNP, FNP-BC
-----------------------------------------------------
Telephone | 808-724-0177
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------