Provider Demographics
NPI:1366545980
Name:ELLIS, TARA FLYNN (BSN RN CNOR RNFA)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:FLYNN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:BSN RN CNOR RNFA
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Mailing Address - Street 1:258 LITTLE HENDRICKS MOUNTAIN RD
Mailing Address - Street 2:#20013
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143-7853
Mailing Address - Country:US
Mailing Address - Phone:770-653-5731
Mailing Address - Fax:770-893-1040
Practice Address - Street 1:1968 PEACHTREE RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309
Practice Address - Country:US
Practice Address - Phone:404-605-3250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GARN097327163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse