Provider Demographics
NPI:1407545841
Name:ELY, ERICA S
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:S
Last Name:ELY
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 1:23875 MICHIGAN AVE # 564
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1805
Mailing Address - Country:US
Mailing Address - Phone:313-502-1626
Mailing Address - Fax:
Practice Address - Street 1:23875 MICHIGAN AVE # 564
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1805
Practice Address - Country:US
Practice Address - Phone:313-502-1626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-02
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide