Provider Demographics
NPI:1336220672
Name:ELLIS, LEEANN (LPN)
Entity Type:Individual
Prefix:
First Name:LEEANN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 OLEANDER TRL
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-5135
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6420 POLLARDS POND RD
Practice Address - Street 2:
Practice Address - City:APPLING
Practice Address - State:GA
Practice Address - Zip Code:30802-3726
Practice Address - Country:US
Practice Address - Phone:706-447-7693
Practice Address - Fax:706-868-3336
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN044588164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse