Provider Demographics
NPI:1356508527
Name:ELLIS, SALLIE R (NURSE)
Entity Type:Individual
Prefix:
First Name:SALLIE
Middle Name:R
Last Name:ELLIS
Suffix:
Gender:F
Credentials:NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 WOODSTOCK AVENUE
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36207-4208
Mailing Address - Country:US
Mailing Address - Phone:256-240-7272
Mailing Address - Fax:256-240-7242
Practice Address - Street 1:1105 WOODSTOCK AVENUE
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36207-4208
Practice Address - Country:US
Practice Address - Phone:256-240-7272
Practice Address - Fax:256-240-7242
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALC08-0119A246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51548269OtherBLUE CROSS BLUE SHIELD