Basic Information
Provider Information | |||||||||
NPI: | 1558389114 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ELLIS | ||||||||
FirstName: | STEFANIE | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5401 ELLSWORTH RD | ||||||||
Address2: |   | ||||||||
City: | FORT SMITH | ||||||||
State: | AR | ||||||||
PostalCode: | 729033219 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4793141101 | ||||||||
FaxNumber: | 4793144704 | ||||||||
Practice Location | |||||||||
Address1: | 2800 FAYETTEVILLE RD | ||||||||
Address2: |   | ||||||||
City: | VAN BUREN | ||||||||
State: | AR | ||||||||
PostalCode: | 729566523 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4793144000 | ||||||||
FaxNumber: | 4793144050 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2006 | ||||||||
LastUpdateDate: | 04/01/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | A01792 | AR | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 5X925 | 01 | AR | AR BCBS | OTHER | 200041860A | 05 | OK |   | MEDICAID | 154409758 | 05 | AR |   | MEDICAID |