Provider Demographics
NPI:1407346810
Name:PARKS, ELLERY
Entity Type:Individual
Prefix:
First Name:ELLERY
Middle Name:
Last Name:PARKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELLERY
Other - Middle Name:
Other - Last Name:LUCAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 73522
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30271-3522
Mailing Address - Country:US
Mailing Address - Phone:877-741-0808
Mailing Address - Fax:
Practice Address - Street 1:72 PRESERVE DR
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-2283
Practice Address - Country:US
Practice Address - Phone:877-741-0808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-11
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA823106024Medicaid