Provider Demographics
NPI:1154073385
Name:ELLIS, KIMBERLY MAXINE
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MAXINE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:MAXINE
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4714 GETTYSBURG RD
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17055-4325
Mailing Address - Country:US
Mailing Address - Phone:717-920-4047
Mailing Address - Fax:
Practice Address - Street 1:2070 CENTURY PARK E
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-1907
Practice Address - Country:US
Practice Address - Phone:424-522-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA01122219376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide