Provider Demographics
NPI:1659457729
Name:SCOTT, JELLISA JUANA (STNA)
Entity Type:Individual
Prefix:MRS
First Name:JELLISA
Middle Name:JUANA
Last Name:SCOTT
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:MS
Other - First Name:JELLISA
Other - Middle Name:JUANA
Other - Last Name:BARNETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:STNA
Mailing Address - Street 1:3920 BRUMBAUGH BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45416-1545
Mailing Address - Country:US
Mailing Address - Phone:937-559-8052
Mailing Address - Fax:
Practice Address - Street 1:3920 BRUMBAUGH BLVD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45416-1545
Practice Address - Country:US
Practice Address - Phone:937-559-8052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400289301003376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH400289301003OtherOHIO DEPT OF HEALTH