Provider Demographics
NPI:1225610223
Name:ELLISON, INDIA PATRICE
Entity Type:Individual
Prefix:
First Name:INDIA
Middle Name:PATRICE
Last Name:ELLISON
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 1:19121 RENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44119-1625
Mailing Address - Country:US
Mailing Address - Phone:216-541-3365
Mailing Address - Fax:
Practice Address - Street 1:19121 RENWOOD AVE
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44119-1625
Practice Address - Country:US
Practice Address - Phone:216-541-3365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-28
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1052Medicaid