Provider Demographics
NPI:1942077318
Name:ELLISON, LAMONT TAIRI
Entity Type:Individual
Prefix:
First Name:LAMONT
Middle Name:TAIRI
Last Name:ELLISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1423 GIRARD ST NW APT 1
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20009-8348
Mailing Address - Country:US
Mailing Address - Phone:240-543-9239
Mailing Address - Fax:
Practice Address - Street 1:1369 IRVING ST NW APT 304
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-7235
Practice Address - Country:US
Practice Address - Phone:202-883-9751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-06
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747P1801X
DC3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant