Provider Demographics
NPI:1972129609
Name:ELLZEY, BONNIE ELIZABETH (FNP-C)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:ELIZABETH
Last Name:ELLZEY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3715 CYPRESS PLANTATION DR
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-7640
Mailing Address - Country:US
Mailing Address - Phone:901-674-4161
Mailing Address - Fax:662-470-6918
Practice Address - Street 1:201 STATELINE RD W STE 5A
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-1600
Practice Address - Country:US
Practice Address - Phone:662-253-8959
Practice Address - Fax:662-470-6918
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-18
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902486163WM0705X
MS904198207Q00000X, 207QA0505X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN30309OtherTN BOARD OF NURSING
MS904198OtherMS BOARD OF NURSING