Provider Demographics
NPI:1043686116
Name:ELLIS, MEGAN
Entity Type:Individual
Prefix:
First Name:MEGAN
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 1:545 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLARENDON
Mailing Address - State:AR
Mailing Address - Zip Code:72029-2017
Mailing Address - Country:US
Mailing Address - Phone:870-830-6805
Mailing Address - Fax:
Practice Address - Street 1:545 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARENDON
Practice Address - State:AR
Practice Address - Zip Code:72029-2017
Practice Address - Country:US
Practice Address - Phone:870-830-6805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT2580171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor