MEDICARE: MRS. AUTUMN DENISE ELLIS FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	29129	TN

General Provider Information

NPI Number	:	1194301242
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AUTUMN DENISE ELLIS FNP-C

Provider Business Mailing Address
First Line	:	3189 GARRETT BALL RD
Second Line	:
City	:	GATES
State	:	TN
Zip	:	38037-5206
Country	:	US
Telephone Number	:	731-694-2872
Fax Number	:

Provider Business Practice Location Address
First Line	:	320 S CHURCH ST
Second Line	:
City	:	HALLS
State	:	TN
Zip	:	38040-1510
Country	:	US
Telephone Number	:	731-836-9303
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/19/2021
Last Update Date	:	03/19/2021

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