Provider Demographics
NPI:1043781925
Name:MEKESA ELLIS, SHANON LEE (NP-C)
Entity Type:Individual
Prefix:
First Name:SHANON
Middle Name:LEE
Last Name:MEKESA ELLIS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5725 DEER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-4185
Mailing Address - Country:US
Mailing Address - Phone:770-841-3785
Mailing Address - Fax:
Practice Address - Street 1:6005 SOM CENTER RD
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-9646
Practice Address - Country:US
Practice Address - Phone:440-946-7252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.024564363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily