Basic Information
| Provider Information | |||||||||
| NPI: | 1649700063 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | LEIGH ANN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4196 HIGHWAY 62 412 STE A | ||||||||
| Address2: | |||||||||
| City: | HARDY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 725428002 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 106 HIGHWAY 62 W | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | AR | ||||||||
| PostalCode: | 725768059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708952015 | ||||||||
| FaxNumber: | 8708952164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2017 | ||||||||
| LastUpdateDate: | 01/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | R005177 | AR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 364SP0808X | A005177 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health |
No ID Information.