Provider Demographics
NPI:1821840083
Name:ELLISON, CARRIE LYNN
Entity Type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:LYNN
Last Name:ELLISON
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 1:1845 CHICAGO AVE STE B
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-2366
Mailing Address - Country:US
Mailing Address - Phone:951-809-0424
Mailing Address - Fax:
Practice Address - Street 1:1845 CHICAGO AVE STE B
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2366
Practice Address - Country:US
Practice Address - Phone:951-465-3664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker