Provider Demographics
NPI:1013565399
Name:ELLIS-KOCEJA, KIMBERLY JEAN
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JEAN
Last Name:ELLIS-KOCEJA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4523 NORTHSHORE RD
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-3478
Mailing Address - Country:US
Mailing Address - Phone:850-596-4137
Mailing Address - Fax:
Practice Address - Street 1:4952 GRASSY POND RD
Practice Address - Street 2:
Practice Address - City:CHIPLEY
Practice Address - State:FL
Practice Address - Zip Code:32428-5547
Practice Address - Country:US
Practice Address - Phone:850-596-4137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider