Provider Demographics
NPI:1376865626
Name:ELLIS, LORA NICOLE (PT)
Entity Type:Individual
Prefix:
First Name:LORA
Middle Name:NICOLE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LORA
Other - Middle Name:NICOLE
Other - Last Name:BASS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:7381 S SIWELL RD
Mailing Address - Street 2:STE A
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39272-8741
Mailing Address - Country:US
Mailing Address - Phone:601-373-2075
Mailing Address - Fax:601-373-2077
Practice Address - Street 1:7381 S SIWELL RD
Practice Address - Street 2:STE A
Practice Address - City:BYRAM
Practice Address - State:MS
Practice Address - Zip Code:39272-8741
Practice Address - Country:US
Practice Address - Phone:601-373-2075
Practice Address - Fax:601-373-2077
Is Sole Proprietor?:No
Enumeration Date:2010-02-26
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT4540225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302I651273Medicare PIN