Provider Demographics
NPI:1821603606
Name:ELLIS, SHERENDA LASHAWN
Entity type:Individual
Prefix:MISS
First Name:SHERENDA
Middle Name:LASHAWN
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 1:1859 PETITE LANE
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058
Mailing Address - Country:US
Mailing Address - Phone:404-421-3809
Mailing Address - Fax:
Practice Address - Street 1:1859 PETITE LANE
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058
Practice Address - Country:US
Practice Address - Phone:404-421-3809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-09
Last Update Date:2025-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X, 171WH0202X, 171WV0202X
GA9Y6C9J8J7246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171WV0202XOther Service ProvidersContractorVehicle Modifications
No171W00000XOther Service ProvidersContractor
No171WH0202XOther Service ProvidersContractorHome Modifications
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Single Specialty