Provider Demographics
NPI:1033254032
Name:ELLIS, TANI K
Entity Type:Individual
Prefix:
First Name:TANI
Middle Name:K
Last Name:ELLIS
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 1:1 CORAL SEA ST
Mailing Address - Street 2:MEDICAL
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-3693
Mailing Address - Country:US
Mailing Address - Phone:808-682-2673
Mailing Address - Fax:808-682-2779
Practice Address - Street 1:1 CORAL SEA ST
Practice Address - Street 2:MEDICAL
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-3693
Practice Address - Country:US
Practice Address - Phone:808-682-2673
Practice Address - Fax:808-682-2779
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider