Provider Demographics
NPI:1184152027
Name:ELLIS, ANN PEYTON (LAT, ATC)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:PEYTON
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 GLEN IVES WAY
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-4606
Mailing Address - Country:US
Mailing Address - Phone:256-698-8809
Mailing Address - Fax:
Practice Address - Street 1:600 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2301
Practice Address - Country:US
Practice Address - Phone:918-456-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-23
Last Update Date:2017-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer