Provider Demographics
NPI:1023726163
Name:ELLIS, BRENDA
Entity type:Individual
Prefix:
First Name:BRENDA
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 1:52 TOWNSHIP ROAD 1124
Mailing Address - Street 2:
Mailing Address - City:PROCTORVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45669-8524
Mailing Address - Country:US
Mailing Address - Phone:304-412-0990
Mailing Address - Fax:
Practice Address - Street 1:52 TOWNSHIP ROAD 1124
Practice Address - Street 2:
Practice Address - City:PROCTORVILLE
Practice Address - State:OH
Practice Address - Zip Code:45669-8524
Practice Address - Country:US
Practice Address - Phone:304-412-0990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant