Provider Demographics
NPI:1578083911
Name:ELLIS, SHONDA LAVERNE
Entity Type:Individual
Prefix:
First Name:SHONDA
Middle Name:LAVERNE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHONDA
Other - Middle Name:LAVERNE
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1450 PETERMAN DR STE A
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3432
Mailing Address - Country:US
Mailing Address - Phone:318-473-4328
Mailing Address - Fax:
Practice Address - Street 1:1450 PETERMAN DR STE A
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301
Practice Address - Country:US
Practice Address - Phone:318-473-4328
Practice Address - Fax:318-473-4328
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator