Provider Demographics
NPI:1447797444
Name:ELLISON, LESHA LORETTA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LESHA
Middle Name:LORETTA
Last Name:ELLISON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2004 CUMBERLAND AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965-1385
Mailing Address - Country:US
Mailing Address - Phone:606-248-3015
Mailing Address - Fax:606-248-3024
Practice Address - Street 1:2004 CUMBERLAND AVE STE 100
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965
Practice Address - Country:US
Practice Address - Phone:606-248-3015
Practice Address - Fax:606-248-3024
Is Sole Proprietor?:No
Enumeration Date:2017-01-27
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC781363A00000X
TNPA3517363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant