Provider Demographics
NPI:1578073722
Name:ELLIS, MELISSA L
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:L
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 1:207 N HWY 59
Mailing Address - Street 2:
Mailing Address - City:KANSAS
Mailing Address - State:OK
Mailing Address - Zip Code:74347-0000
Mailing Address - Country:US
Mailing Address - Phone:918-786-4434
Mailing Address - Fax:918-786-4435
Practice Address - Street 1:207 N HWY 59
Practice Address - Street 2:
Practice Address - City:KANSAS
Practice Address - State:OK
Practice Address - Zip Code:74347-0000
Practice Address - Country:US
Practice Address - Phone:918-786-4434
Practice Address - Fax:918-786-4435
Is Sole Proprietor?:No
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator