Provider Demographics
NPI:1366564809
Name:ELLIS, NANCY LYNNE (MD)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:LYNNE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:939 SNOWDEN FARM RD
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-8988
Mailing Address - Country:US
Mailing Address - Phone:901-860-0687
Mailing Address - Fax:901-850-8489
Practice Address - Street 1:1400 DOWELL SPRINGS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-2457
Practice Address - Country:US
Practice Address - Phone:865-584-0291
Practice Address - Fax:865-584-4426
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS096082085R0202X
TN136982085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0012597Medicaid
TNQ052520Medicaid
MS0012597Medicaid