Provider Demographics
NPI:1306363601
Name:ELLIS, HANNAH
Entity Type:Individual
Prefix:
First Name:HANNAH
Middle Name:
Last Name:ELLIS
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 1:102 SOLITUDE WAY
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-8994
Mailing Address - Country:US
Mailing Address - Phone:919-349-0003
Mailing Address - Fax:919-917-7681
Practice Address - Street 1:2817 TOBERMORY LN
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27606-4443
Practice Address - Country:US
Practice Address - Phone:919-917-7681
Practice Address - Fax:919-917-7681
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-28
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC273197674Medicaid