Provider Demographics
NPI:1629696711
Name:ELLISON, LATONIYA CHEVELLE (LPN)
Entity Type:Individual
Prefix:
First Name:LATONIYA
Middle Name:CHEVELLE
Last Name:ELLISON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 DA VINCI ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-3341
Mailing Address - Country:US
Mailing Address - Phone:919-593-1592
Mailing Address - Fax:
Practice Address - Street 1:819 DA VINCI ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-3341
Practice Address - Country:US
Practice Address - Phone:919-593-1592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-06
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC53253164W00000X
253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No253Z00000XAgenciesIn Home Supportive Care