Provider Demographics
NPI:1265153548
Name:CARRICO ELLIS, ANNIE
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:CARRICO ELLIS
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 1:3908 ALAMEDA AVE APT A
Mailing Address - Street 2:
Mailing Address - City:CAPITOLA
Mailing Address - State:CA
Mailing Address - Zip Code:95010-2945
Mailing Address - Country:US
Mailing Address - Phone:408-239-7224
Mailing Address - Fax:
Practice Address - Street 1:3908 ALAMEDA AVE APT A
Practice Address - Street 2:
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010-2945
Practice Address - Country:US
Practice Address - Phone:408-239-7224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist