Provider Demographics
NPI:1992014971
Name:ELLIS, KELLY MICHELLE
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:MICHELLE
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 1:2407 PERRY ST
Mailing Address - Street 2:
Mailing Address - City:BAYTOWN
Mailing Address - State:TX
Mailing Address - Zip Code:77521-1074
Mailing Address - Country:US
Mailing Address - Phone:281-896-1198
Mailing Address - Fax:
Practice Address - Street 1:4230 TREE MOSS PL
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77346-4560
Practice Address - Country:US
Practice Address - Phone:281-454-4497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPT14091246RP1900X
CACERTIFIED BIOTECH246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other