Provider Demographics
NPI:1104713403
Name:ELLIS-WILLIAMS, KENYETTA T
Entity type:Individual
Prefix:
First Name:KENYETTA
Middle Name:T
Last Name:ELLIS-WILLIAMS
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 1:4901 SPRING GARDEN DR STE LL
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-4670
Mailing Address - Country:US
Mailing Address - Phone:410-812-4253
Mailing Address - Fax:443-249-9951
Practice Address - Street 1:4901 SPRING GARDEN DR STE LL
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-4670
Practice Address - Country:US
Practice Address - Phone:410-812-4253
Practice Address - Fax:443-249-9951
Is Sole Proprietor?:No
Enumeration Date:2025-06-19
Last Update Date:2025-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR225384163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse