Provider Demographics
NPI:1417691486
Name:ELLISON, DAVIONE
Entity Type:Individual
Prefix:
First Name:DAVIONE
Middle Name:
Last Name:ELLISON
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 1:4713 E 80TH ST APT 8C
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-8951
Mailing Address - Country:US
Mailing Address - Phone:682-241-6967
Mailing Address - Fax:
Practice Address - Street 1:2442 MOHAWK BLVD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74110-1519
Practice Address - Country:US
Practice Address - Phone:918-430-0597
Practice Address - Fax:918-430-0995
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator