Provider Demographics
NPI:1831310317
Name:ELLISON, ANGELIA MARIE (LMT)
Entity Type:Individual
Prefix:MS
First Name:ANGELIA
Middle Name:MARIE
Last Name:ELLISON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 SATSUMA DR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-3650
Mailing Address - Country:US
Mailing Address - Phone:407-256-3243
Mailing Address - Fax:
Practice Address - Street 1:5030 S US HIGHWAY 17/92
Practice Address - Street 2:
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707-3869
Practice Address - Country:US
Practice Address - Phone:407-256-3243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA42490225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist