Provider Demographics
NPI:1679143077
Name:ELLIS, DANA DEPAUL (LAC)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:DEPAUL
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2523 BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:PA
Mailing Address - Zip Code:19003-2616
Mailing Address - Country:US
Mailing Address - Phone:202-315-8283
Mailing Address - Fax:
Practice Address - Street 1:32 SUMMIT GROVE AVE
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-3212
Practice Address - Country:US
Practice Address - Phone:484-362-9171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAK001144171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist