Provider Demographics
NPI:1205455789
Name:ELLIS, KELLY WYNELL (PTA)
Entity type:Individual
Prefix:MR
First Name:KELLY
Middle Name:WYNELL
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5502 SAN JUAN DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43612-3336
Mailing Address - Country:US
Mailing Address - Phone:419-410-7741
Mailing Address - Fax:
Practice Address - Street 1:5502 SAN JUAN DR
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43612-3336
Practice Address - Country:US
Practice Address - Phone:419-410-7741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-14
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA007644208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation