Individual
TARA RUSSELL ELLIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
2680 ELMS PLANTATION BLVD, NORTH CHARLESTON, SC 29406-7101
(843) 439-6181
Mailing address
2680 ELMS PLANTATION BLVD, NORTH CHARLESTON, SC 29406-7101
(843) 813-2914
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
25495
SC
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
04/12/2021
Last updated
01/20/2022
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