Provider Demographics
NPI:1710583117
Name:ELLIS, MELINDA
Entity Type:Individual
Prefix:
First Name:MELINDA
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:PO BOX 1346
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-1346
Mailing Address - Country:US
Mailing Address - Phone:304-752-6868
Mailing Address - Fax:304-752-1047
Practice Address - Street 1:699 STRATTON ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-4020
Practice Address - Country:US
Practice Address - Phone:304-752-6868
Practice Address - Fax:304-752-1047
Is Sole Proprietor?:No
Enumeration Date:2020-12-10
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker