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General NPI Number Information
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NPI Number | 1972129609
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Entity Type | Individual
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Provider Name | BONNIE ELIZABETH ELLZEY FNP-C
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Gender | Female
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Dates
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Enumeration Date | 06/18/2020
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Last Update Date | 06/24/2022
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Provider Practice Location Address
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Address Line | 201 STATELINE RD W STE 5A
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City | SOUTHAVEN
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State | MS
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Zip | 38671-1600
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Country | US
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Telephone | 662-253-8959
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Fax | 662-470-6918
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Provider Business Mailing Address
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Address Line | 3715 CYPRESS PLANTATION DR
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City | OLIVE BRANCH
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State | MS
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Zip | 38654-7640
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Country | US
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Telephone | 901-674-4161
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Fax | 662-470-6918
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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 | 163WM0705X
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Taxonomy Name | Medical-Surgical Registered Nurse
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License Number | 902486
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 904198
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License Number State | MS
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Taxonomy #3
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Taxonomy Code | 207QA0505X
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Taxonomy Name | Adult Medicine Physician
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License Number | 904198
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License Number State | MS
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Taxonomy #4
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 904198
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License Number State | MS
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