Provider Demographics
NPI:1043924038
Name:ELLISON, LATOYA FENE
Entity Type:Individual
Prefix:
First Name:LATOYA
Middle Name:FENE
Last Name:ELLISON
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 1:161 W UNIVERSITY PKWY # 10861
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-1857
Mailing Address - Country:US
Mailing Address - Phone:731-265-6787
Mailing Address - Fax:
Practice Address - Street 1:26 BENT TREE CV
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-8935
Practice Address - Country:US
Practice Address - Phone:731-267-0669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-13
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor