Provider Demographics
NPI:1740042282
Name:ELLIS, SHAUNDRA LYN
Entity type:Individual
Prefix:
First Name:SHAUNDRA
Middle Name:LYN
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 1:22 SW 51ST ST
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-6827
Mailing Address - Country:US
Mailing Address - Phone:580-483-8453
Mailing Address - Fax:
Practice Address - Street 1:22 SW 51ST ST
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-6827
Practice Address - Country:US
Practice Address - Phone:580-483-8453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator