Provider Demographics
NPI:1821490996
Name:ELLIS, LANI (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LANI
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 SHIPYARD BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-6431
Mailing Address - Country:US
Mailing Address - Phone:910-343-0145
Mailing Address - Fax:910-202-9966
Practice Address - Street 1:584 HOSPITAL DR NE UNIT C
Practice Address - Street 2:
Practice Address - City:BOLIVIA
Practice Address - State:NC
Practice Address - Zip Code:28422
Practice Address - Country:US
Practice Address - Phone:910-721-4100
Practice Address - Fax:910-721-4101
Is Sole Proprietor?:No
Enumeration Date:2014-09-20
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004612363A00000X
VA110004612363AM0700X
NC0010-07945363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical