Provider Demographics
NPI:1508178112
Name:ELLIS, KATHERINE H (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:H
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:H
Other - Last Name:RACICOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:304 S WEST ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-5916
Mailing Address - Country:US
Mailing Address - Phone:240-688-0757
Mailing Address - Fax:
Practice Address - Street 1:304 S WEST ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-5916
Practice Address - Country:US
Practice Address - Phone:240-688-0757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-12
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101252136207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine