Provider Demographics
NPI:1043363856
Name:ELLIS, NANCY
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
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:ELLIS OPTICAL SHOPPE
Mailing Address - Street 2:2302 12TH ST.
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-2634
Mailing Address - Country:US
Mailing Address - Phone:601-482-4042
Mailing Address - Fax:
Practice Address - Street 1:ELLIS OPTICAL SHOPPE
Practice Address - Street 2:2302 12TH ST.
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-2634
Practice Address - Country:US
Practice Address - Phone:601-482-4042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0631310001Medicare ID - Type UnspecifiedGRP #