Provider Demographics
NPI:1437747235
Name:ELLIS-SUTTON, TASHIKA
Entity Type:Individual
Prefix:MRS
First Name:TASHIKA
Middle Name:
Last Name:ELLIS-SUTTON
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 1:1625 SW LA GORCE AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-2568
Mailing Address - Country:US
Mailing Address - Phone:772-777-0624
Mailing Address - Fax:
Practice Address - Street 1:1625 SW LA GORCE AVE
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-2568
Practice Address - Country:US
Practice Address - Phone:772-777-0624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRN-99566163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse