Provider Demographics
NPI:1356933402
Name:ELLIS, DIAN T
Entity type:Individual
Prefix:
First Name:DIAN
Middle Name:T
Last Name: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 1:5536 KAREN ELAINE DR APT 1606
Mailing Address - Street 2:
Mailing Address - City:NEW CARROLLTON
Mailing Address - State:MD
Mailing Address - Zip Code:20784-4149
Mailing Address - Country:US
Mailing Address - Phone:202-207-0760
Mailing Address - Fax:
Practice Address - Street 1:5536 KAREN ELAINE DR APT 1606
Practice Address - Street 2:
Practice Address - City:NEW CARROLLTON
Practice Address - State:MD
Practice Address - Zip Code:20784-4149
Practice Address - Country:US
Practice Address - Phone:202-207-0760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDCNA20210460374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide