Provider Demographics
NPI:1083038137
Name:ELLIS, YAVONNE L (LPN)
Entity Type:Individual
Prefix:
First Name:YAVONNE
Middle Name:L
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 CHESTER RIVER BEACH RD
Mailing Address - Street 2:
Mailing Address - City:GRASONVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21638
Mailing Address - Country:US
Mailing Address - Phone:202-391-4837
Mailing Address - Fax:410-827-4727
Practice Address - Street 1:619 CHESTER RIVER BEACH RD
Practice Address - Street 2:
Practice Address - City:GRASONVILLE
Practice Address - State:MD
Practice Address - Zip Code:21638
Practice Address - Country:US
Practice Address - Phone:202-391-4837
Practice Address - Fax:410-827-4727
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-10
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLP48536164W00000X
DCLPN1006048164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD46-5172239OtherEIN