Provider Demographics
NPI:1790433605
Name:ELLIS, MANDIE (DAOM)
Entity Type:Individual
Prefix:
First Name:MANDIE
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 WOODSTOCK AVE
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-1429
Mailing Address - Country:US
Mailing Address - Phone:978-798-8804
Mailing Address - Fax:
Practice Address - Street 1:1991 VICTORY HWY
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:RI
Practice Address - Zip Code:02826-1670
Practice Address - Country:US
Practice Address - Phone:401-710-4207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDAOM00088171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist