Provider Demographics
NPI:1972947810
Name:ELLIS, JERMAINE SHANIN
Entity Type:Individual
Prefix:
First Name:JERMAINE
Middle Name:SHANIN
Last Name:ELLIS
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 1:4323 THOMPSON AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-1622
Mailing Address - Country:US
Mailing Address - Phone:907-230-3379
Mailing Address - Fax:
Practice Address - Street 1:1058 W 27TH AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-2424
Practice Address - Country:US
Practice Address - Phone:907-274-7391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-22
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider