Provider Demographics
NPI:1205621901
Name:ELLIS, CODY W (RD)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:W
Last Name:ELLIS
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16039 LAVENHAM RD
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-5660
Mailing Address - Country:US
Mailing Address - Phone:803-517-6319
Mailing Address - Fax:
Practice Address - Street 1:16039 LAVENHAM RD
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-5660
Practice Address - Country:US
Practice Address - Phone:803-517-6319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-12
Last Update Date:2025-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC86299004133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered