Provider Demographics
NPI:1154442200
Name:ELLIS, MIREILLE F (PA)
Entity Type:Individual
Prefix:
First Name:MIREILLE
Middle Name:F
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5835 LENOX PARK PL
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-7690
Mailing Address - Country:US
Mailing Address - Phone:602-684-4682
Mailing Address - Fax:
Practice Address - Street 1:2650 HOLCOMB BRIDGE RD STE 510
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-5374
Practice Address - Country:US
Practice Address - Phone:404-255-4080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6652363A00000X
GA001471133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant