Provider Demographics
NPI:1760174049
Name:ELLZEY, ASHLEI CHULETTE
Entity Type:Individual
Prefix:
First Name:ASHLEI
Middle Name:CHULETTE
Last Name:ELLZEY
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 1:245 EDGAR HOLMES RD LOT 1
Mailing Address - Street 2:
Mailing Address - City:TYLERTOWN
Mailing Address - State:MS
Mailing Address - Zip Code:39667-5449
Mailing Address - Country:US
Mailing Address - Phone:601-441-5579
Mailing Address - Fax:
Practice Address - Street 1:245 EDGAR HOLMES RD LOT 1
Practice Address - Street 2:
Practice Address - City:TYLERTOWN
Practice Address - State:MS
Practice Address - Zip Code:39667-5449
Practice Address - Country:US
Practice Address - Phone:601-441-5579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory