Provider Demographics
NPI:1518455716
Name:ELLIS, GWYNDOLYN (RN, LAT, ATC)
Entity type:Individual
Prefix:
First Name:GWYNDOLYN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RN, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 CANTERBURY DR
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79602-4258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 CAMPUS CT
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79699-5318
Practice Address - Country:US
Practice Address - Phone:325-674-2323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2024-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX922427163W00000X
TXAT72182255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No163W00000XNursing Service ProvidersRegistered Nurse
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer