Provider Demographics
NPI:1164978466
Name:ELLIS, SUZANNE
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
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 1:114 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:OH
Mailing Address - Zip Code:43343
Mailing Address - Country:US
Mailing Address - Phone:937-538-7619
Mailing Address - Fax:
Practice Address - Street 1:114 SOUTH ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:OH
Practice Address - Zip Code:43343
Practice Address - Country:US
Practice Address - Phone:937-538-7619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0172435146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic