Provider Demographics
NPI:1922441252
Name:ELLIS, STASIA
Entity Type:Individual
Prefix:
First Name:STASIA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STASIA
Other - Middle Name:
Other - Last Name:O'CONNOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1623 MILL BAY RD
Mailing Address - Street 2:STE. 2
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-6200
Mailing Address - Country:US
Mailing Address - Phone:907-512-2500
Mailing Address - Fax:
Practice Address - Street 1:1623 MILL BAY RD
Practice Address - Street 2:STE. 2
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6200
Practice Address - Country:US
Practice Address - Phone:907-512-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-17
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator