=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508318494
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEISHA ELLIS NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2016
-----------------------------------------------------
Last Update Date | 12/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7649 W COLONIAL DR STE 115
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32818-7423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-522-2080
-----------------------------------------------------
Fax | 833-963-0115
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6101 BLUE LAGOON DR STE 200
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33126-3168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-630-0700
-----------------------------------------------------
Fax | 877-374-1924
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | CNP-03387
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APRN9281197
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | CNP03387
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------