Provider Demographics
NPI:1639385925
Name:ELLIS, TAMIKA CLARICE (LPN)
Entity Type:Individual
Prefix:
First Name:TAMIKA
Middle Name:CLARICE
Last Name:ELLIS
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 1:5354 ASHFORD RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-6005
Mailing Address - Country:US
Mailing Address - Phone:419-290-3824
Mailing Address - Fax:
Practice Address - Street 1:5354 ASHFORD RIDGE RD
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-6005
Practice Address - Country:US
Practice Address - Phone:419-290-3824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN-114184164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2574790OtherINDEPENDENT PROVIDER
OH2574790Medicaid