MEDICARE: DAN ELLIS GNP INC

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	363LG0600X	Gerontology Nurse Practitioner	R826981	MS

General Provider Information

NPI Number	:	1942552732
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAN ELLIS GNP INC

Provider Business Mailing Address
First Line	:	PO BOX 215
Second Line	:
City	:	UTICA
State	:	MS
Zip	:	39175-0215
Country	:	US
Telephone Number	:	601-529-2871
Fax Number	:	601-629-9969

Provider Business Practice Location Address
First Line	:	703B FARMER ST
Second Line	:
City	:	PORT GIBSON
State	:	MS
Zip	:	39150-2319
Country	:	US
Telephone Number	:	601-529-2871
Fax Number	:	601-629-9969

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DAN ELLIS
Credential	:
Telephone Number	:	601-636-0097

Provider Enumeration Date	:	10/04/2012
Last Update Date	:	12/26/2012

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