Provider Demographics
NPI:1114176625
Name:ELLIS, KATHRYNE (MA, CN)
Entity Type:Individual
Prefix:
First Name:KATHRYNE
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MA, CN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 STOCKTON BLVD
Mailing Address - Street 2:
Mailing Address - City:SEA GIRT
Mailing Address - State:NJ
Mailing Address - Zip Code:08750-3225
Mailing Address - Country:US
Mailing Address - Phone:732-449-0076
Mailing Address - Fax:732-449-7116
Practice Address - Street 1:112 STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:SEA GIRT
Practice Address - State:NJ
Practice Address - Zip Code:08750-3225
Practice Address - Country:US
Practice Address - Phone:732-449-0076
Practice Address - Fax:732-449-7116
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist