1760550990 NPI number — DONNA A THOMAS ELLIS CFNP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760550990 NPI number — DONNA A THOMAS ELLIS CFNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMAS ELLIS
Provider First Name:
DONNA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CFNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
THOMAS
Provider Other First Name:
DONNA
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CFNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760550990
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/24/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 321359
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLOWOOD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39232-1359
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-933-5417
Provider Business Mailing Address Fax Number:
601-936-1336

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1040 N FLOWOOD DR STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLOWOOD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39232-9789
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-933-5417
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  602612 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 05457378 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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