Provider Demographics
NPI:1578825287
Name:ELLIS, EDWANDRA
Entity Type:Individual
Prefix:
First Name:EDWANDRA
Middle Name:
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 1:1428 SARATOGA AVE NE
Mailing Address - Street 2:#11
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20018-1912
Mailing Address - Country:US
Mailing Address - Phone:202-374-8584
Mailing Address - Fax:
Practice Address - Street 1:1428 SARATOGA AVE NE
Practice Address - Street 2:#11
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-1912
Practice Address - Country:US
Practice Address - Phone:202-374-8584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-10
Last Update Date:2012-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC2490646374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide