Provider Demographics
NPI:1417392192
Name:ELLIS, CALLIE
Entity Type:Individual
Prefix:
First Name:CALLIE
Middle Name:
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 1:4991 LAKE BROOK DR STE 300
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9293
Mailing Address - Country:US
Mailing Address - Phone:804-837-4578
Mailing Address - Fax:855-849-1894
Practice Address - Street 1:4991 LAKE BROOK DR STE 300
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-9293
Practice Address - Country:US
Practice Address - Phone:804-837-4578
Practice Address - Fax:855-849-1894
Is Sole Proprietor?:No
Enumeration Date:2013-05-08
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor