Provider Demographics
NPI:1326343765
Name:ELLIS, SELINA Y
Entity Type:Individual
Prefix:MRS
First Name:SELINA
Middle Name:Y
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:PO BOX 81314
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-9314
Mailing Address - Country:US
Mailing Address - Phone:770-679-5714
Mailing Address - Fax:888-273-6606
Practice Address - Street 1:2055 GEES MILL RD NE
Practice Address - Street 2:SUITE 327
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-1362
Practice Address - Country:US
Practice Address - Phone:770-679-5714
Practice Address - Fax:888-273-6606
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-16
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA372600000X, 376K00000X
3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No372600000XNursing Service Related ProvidersAdult Companion
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider