Provider Demographics
NPI:1750752622
Name:ELLIS, LOLITA
Entity type:Individual
Prefix:
First Name:LOLITA
Middle Name:
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 1:206 E IOWA AVE
Mailing Address - Street 2:
Mailing Address - City:BONIFAY
Mailing Address - State:FL
Mailing Address - Zip Code:32425-2208
Mailing Address - Country:US
Mailing Address - Phone:850-849-3869
Mailing Address - Fax:850-547-1568
Practice Address - Street 1:206 E IOWA AVE
Practice Address - Street 2:
Practice Address - City:BONIFAY
Practice Address - State:FL
Practice Address - Zip Code:32425-2208
Practice Address - Country:US
Practice Address - Phone:850-849-3869
Practice Address - Fax:850-547-1568
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-16
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL166844376K00000X, 374U00000X, 376J00000X, 3747A0650X
372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL607114OtherATN