Provider Demographics
NPI:1265131247
Name:ELIS, KATONIA
Entity type:Individual
Prefix:
First Name:KATONIA
Middle Name:
Last Name:ELIS
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:PO BOX 1147
Mailing Address - Street 2:
Mailing Address - City:EXPERIMENT
Mailing Address - State:GA
Mailing Address - Zip Code:30212-1147
Mailing Address - Country:US
Mailing Address - Phone:470-808-0131
Mailing Address - Fax:
Practice Address - Street 1:101 HILLPINE TRL # A
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-2531
Practice Address - Country:US
Practice Address - Phone:678-852-5545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-28
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054356109172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty