Basic Information
| Provider Information | |||||||||
| NPI: | 1174537294 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLERBY | ||||||||
| FirstName: | CHARLOTTE | ||||||||
| MiddleName: | LATRICE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1624 WESTGATE CIR | ||||||||
| Address2: | SUITE 175 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370278053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8772304624 | ||||||||
| FaxNumber: | 8778393307 | ||||||||
| Practice Location | |||||||||
| Address1: | 3939 HILLSBORO CIR | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372152708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6156736737 | ||||||||
| FaxNumber: | 8004744039 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 05/02/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APN0000008295 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1504913 | 05 | TN | MEDICAID |