Provider Demographics
NPI:1649694829
Name:ELLIS, JULIE MARIA
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:MARIA
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 1:4916 DAVIDSON RUN DR
Mailing Address - Street 2:
Mailing Address - City:HILLIARD
Mailing Address - State:OH
Mailing Address - Zip Code:43026-3826
Mailing Address - Country:US
Mailing Address - Phone:614-499-5218
Mailing Address - Fax:
Practice Address - Street 1:4916 DAVIDSON RUN DR
Practice Address - Street 2:
Practice Address - City:HILLIARD
Practice Address - State:OH
Practice Address - Zip Code:43026-3826
Practice Address - Country:US
Practice Address - Phone:614-499-5218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-09
Last Update Date:2014-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT4212171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor