Provider Demographics
NPI:1235659897
Name:ELLISON, BRITTANY LATRESE (CNM)
Entity Type:Individual
Prefix:MRS
First Name:BRITTANY
Middle Name:LATRESE
Last Name:ELLISON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 VIRGINIA RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338-4793
Mailing Address - Country:US
Mailing Address - Phone:404-205-0176
Mailing Address - Fax:
Practice Address - Street 1:1015 MANSELL RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1507
Practice Address - Country:US
Practice Address - Phone:770-521-2229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-26
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN203967367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife