Provider Demographics
NPI:1023735834
Name:ELLIS, GRETCHEL (GRETCHEL ELLIS)
Entity type:Individual
Prefix:
First Name:GRETCHEL
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:GRETCHEL ELLIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 APPLEWHITE ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71302-6218
Mailing Address - Country:US
Mailing Address - Phone:318-664-0966
Mailing Address - Fax:
Practice Address - Street 1:707 APPLEWHITE ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71302-6218
Practice Address - Country:US
Practice Address - Phone:318-664-0966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-21
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11529227374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide