Provider Demographics
NPI:1942876966
Name:ELLIS, LACRESHA
Entity Type:Individual
Prefix:
First Name:LACRESHA
Middle Name:
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 1:4603 BRICKWOOD MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:NORTH DINWIDDIE
Mailing Address - State:VA
Mailing Address - Zip Code:23803-8875
Mailing Address - Country:US
Mailing Address - Phone:804-895-8450
Mailing Address - Fax:
Practice Address - Street 1:4603 BRICKWOOD MEADOW DR
Practice Address - Street 2:
Practice Address - City:NORTH DINWIDDIE
Practice Address - State:VA
Practice Address - Zip Code:23803-8875
Practice Address - Country:US
Practice Address - Phone:804-895-8450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-01
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)