Provider Demographics
NPI:1942871629
Name:ELLIS, SARA ANGELIQUE
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:ANGELIQUE
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 1:619 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-4431
Mailing Address - Country:US
Mailing Address - Phone:918-682-8407
Mailing Address - Fax:
Practice Address - Street 1:6365 W OKMULGEE ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-4595
Practice Address - Country:US
Practice Address - Phone:918-687-1039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-05
Last Update Date:2021-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator