Provider Demographics
NPI:1629472550
Name:ELLIS, ANDREA
Entity Type:Individual
Prefix:
First Name:ANDREA
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 1:1624 MAIN STREET
Mailing Address - Street 2:AGAPE SENIOR PRIMARY CARE, INC., DBA AGAPE PHYSICIANS C
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201
Mailing Address - Country:US
Mailing Address - Phone:803-454-0365
Mailing Address - Fax:803-404-6000
Practice Address - Street 1:3525 AUGUSTUS ROAD
Practice Address - Street 2:AGAPE PHYSICIANS CARE
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801
Practice Address - Country:US
Practice Address - Phone:803-454-3510
Practice Address - Fax:803-454-2368
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-21
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18950363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care