Provider Demographics
NPI:1215408919
Name:ELLIS, CORINNE (RDN, LDN)
Entity Type:Individual
Prefix:
First Name:CORINNE
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 N 21ST ST APT 1
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-1402
Mailing Address - Country:US
Mailing Address - Phone:774-278-0351
Mailing Address - Fax:
Practice Address - Street 1:123 S BROAD ST STE 1641
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19109-1027
Practice Address - Country:US
Practice Address - Phone:267-205-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-07
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN006615133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered