Provider Demographics
NPI:1134904105
Name:ELLZEY, KIMONI
Entity type:Individual
Prefix:
First Name:KIMONI
Middle Name:
Last Name:ELLZEY
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 1:5850 FLORIDA BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-4247
Mailing Address - Country:US
Mailing Address - Phone:225-935-9923
Mailing Address - Fax:
Practice Address - Street 1:5850 FLORIDA BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-4247
Practice Address - Country:US
Practice Address - Phone:225-935-9923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant