Provider Demographics
NPI:1275304453
Name:ELLIS, DONNA (LAC)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 LARKSPUR LN
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-2305
Mailing Address - Country:US
Mailing Address - Phone:276-293-1125
Mailing Address - Fax:
Practice Address - Street 1:146 LARKSPUR LN
Practice Address - Street 2:
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-2305
Practice Address - Country:US
Practice Address - Phone:828-230-2517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121001146171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist