Provider Demographics
NPI:1306360060
Name:ELLIS, KAMEELAH L (NP)
Entity Type:Individual
Prefix:
First Name:KAMEELAH
Middle Name:L
Last Name:ELLIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1631
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-1631
Mailing Address - Country:US
Mailing Address - Phone:404-314-8868
Mailing Address - Fax:
Practice Address - Street 1:33 UPPER RIVERDALE RD SW STE 21
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2617
Practice Address - Country:US
Practice Address - Phone:404-314-8868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA179861363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner