Provider Demographics
NPI:1578075784
Name:ELLIS, GERI ANN (ATC)
Entity Type:Individual
Prefix:
First Name:GERI
Middle Name:ANN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 FREEMAN ST
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:IL
Mailing Address - Zip Code:62906-1505
Mailing Address - Country:US
Mailing Address - Phone:618-697-2810
Mailing Address - Fax:618-697-2810
Practice Address - Street 1:326 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:62896-2402
Practice Address - Country:US
Practice Address - Phone:618-847-0683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-27
Last Update Date:2017-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0045282255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer