Provider Demographics
NPI:1093359556
Name:ELLIS, LEONORA M
Entity Type:Individual
Prefix:MS
First Name:LEONORA
Middle Name:M
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 1:2 LARUE AVE APT B6
Mailing Address - Street 2:
Mailing Address - City:EGG HARBOR TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08234-1628
Mailing Address - Country:US
Mailing Address - Phone:856-982-3432
Mailing Address - Fax:
Practice Address - Street 1:2 LARUE AVE APT B6
Practice Address - Street 2:
Practice Address - City:EGG HARBOR TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08234-1628
Practice Address - Country:US
Practice Address - Phone:856-982-3432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty