Provider Demographics
NPI:1174013650
Name:XU, ELLA DONGQING
Entity Type:Individual
Prefix:
First Name:ELLA
Middle Name:DONGQING
Last Name:XU
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 1:3099 DEVAUDEN CT
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-3534
Mailing Address - Country:US
Mailing Address - Phone:470-858-7030
Mailing Address - Fax:
Practice Address - Street 1:3099 DEVAUDEN CT
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-3534
Practice Address - Country:US
Practice Address - Phone:470-858-7030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA424171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA054098980Medicaid