MEDICARE: DR. LEIGH ANN ELLIS DNP

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	364SP0808X	Psychiatric/Mental Health Clinical Nurse Specialist	A005177	AR
2	363LG0600X	Gerontology Nurse Practitioner	R005177	AR

General Provider Information

NPI Number	:	1649700063
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEIGH ANN ELLIS DNP

Provider Business Mailing Address
First Line	:	1327 N MONTVIEW DR
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72701-2867
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1327 N MONTVIEW DR
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72701-2867
Country	:	US
Telephone Number	:	206-245-0526
Fax Number	:

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

Provider Enumeration Date	:	06/18/2017
Last Update Date	:	12/10/2025

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