Provider Demographics
NPI:1689388480
Name:ELLIS, AMANDA (PA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1923 SULPHUR SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37813-5654
Mailing Address - Country:US
Mailing Address - Phone:423-312-8165
Mailing Address - Fax:423-714-2355
Practice Address - Street 1:880 RUTLEDGE PIKE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:TN
Practice Address - Zip Code:37709-2317
Practice Address - Country:US
Practice Address - Phone:865-933-4110
Practice Address - Fax:865-933-4729
Is Sole Proprietor?:No
Enumeration Date:2023-01-06
Last Update Date:2025-07-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X, 363AM0700X
TN6356363AM0700X
NVRN88608163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No163WE0003XNursing Service ProvidersRegistered NurseEmergency