Provider Demographics
NPI:1497297329
Name:ELLIS-VEAL, BERNICE (LPN)
Entity Type:Individual
Prefix:
First Name:BERNICE
Middle Name:
Last Name:ELLIS-VEAL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:BERNICE
Other - Middle Name:
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2238 NANTUCKET CT NE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-2128
Mailing Address - Country:US
Mailing Address - Phone:706-223-7800
Mailing Address - Fax:
Practice Address - Street 1:2238 NANTUCKET CT NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-2128
Practice Address - Country:US
Practice Address - Phone:706-223-7800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN087320164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse