Provider Demographics
NPI:1477853398
Name:ELLIS, SHANIQUAL
Entity Type:Individual
Prefix:
First Name:SHANIQUAL
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 1:715 N COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-4403
Mailing Address - Country:US
Mailing Address - Phone:870-862-7921
Mailing Address - Fax:870-864-2490
Practice Address - Street 1:211 JACKSON ST SW
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:AR
Practice Address - Zip Code:71701-3941
Practice Address - Country:US
Practice Address - Phone:870-836-5743
Practice Address - Fax:870-836-6924
Is Sole Proprietor?:No
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator