Provider Demographics
NPI:1609458090
Name:ELLISON, CYDNEE YOLETTE (PA-C)
Entity Type:Individual
Prefix:
First Name:CYDNEE
Middle Name:YOLETTE
Last Name:ELLISON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33133-4828
Mailing Address - Country:US
Mailing Address - Phone:305-725-7658
Mailing Address - Fax:
Practice Address - Street 1:5340 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:LIGHTHOUSE POINT
Practice Address - State:FL
Practice Address - Zip Code:33064-7058
Practice Address - Country:US
Practice Address - Phone:954-428-2480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-25
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLPA9116902363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program