Provider Demographics
NPI:1528569027
Name:JELKS-ERMATOV, VENECIA
Entity Type:Individual
Prefix:
First Name:VENECIA
Middle Name:
Last Name:JELKS-ERMATOV
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 1:919 LAWYERS LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31906-3129
Mailing Address - Country:US
Mailing Address - Phone:706-256-3200
Mailing Address - Fax:
Practice Address - Street 1:919 LAWYERS LN
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31906-3129
Practice Address - Country:US
Practice Address - Phone:706-256-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker