MEDICARE: MS. MARLENA SHANDRELL ELLIS FNP

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	ARNP9345611	FL

General Provider Information

NPI Number	:	1477008837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARLENA SHANDRELL ELLIS FNP

Provider Business Mailing Address
First Line	:	12171 SW 268TH ST
Second Line	:
City	:	HOMESTEAD
State	:	FL
Zip	:	33032-8001
Country	:	US
Telephone Number	:	305-278-0200
Fax Number	:	786-430-1583

Provider Business Practice Location Address
First Line	:	500 MCDUFF AVE S
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32254-4250
Country	:	US
Telephone Number	:	904-506-4044
Fax Number	:	904-490-8544

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

Provider Enumeration Date	:	08/15/2016
Last Update Date	:	03/16/2020

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