Provider Demographics
NPI:1598841256
Name:ELLIS, ROSEANNE DISHMAN (DC)
Entity Type:Individual
Prefix:
First Name:ROSEANNE
Middle Name:DISHMAN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:ROSEANNE
Other - Middle Name:ELLIS
Other - Last Name:DISHMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:135 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-3927
Mailing Address - Country:US
Mailing Address - Phone:931-528-8362
Mailing Address - Fax:931-528-8657
Practice Address - Street 1:135 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-3927
Practice Address - Country:US
Practice Address - Phone:931-528-8362
Practice Address - Fax:931-528-8657
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDC430111N00000X
VA104000516111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN57197OtherBCBS
TN3673597Medicaid
TN57197OtherBCBS
TN3673597Medicaid