Provider Demographics
NPI:1770175788
Name:ELLERSON, ANESSIA NICHOLE
Entity type:Individual
Prefix:
First Name:ANESSIA
Middle Name:NICHOLE
Last Name:ELLERSON
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 1:104 BAMBOO DR
Mailing Address - Street 2:
Mailing Address - City:KINGSLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31548-6110
Mailing Address - Country:US
Mailing Address - Phone:904-431-9296
Mailing Address - Fax:
Practice Address - Street 1:1699 S 14TH ST STE 2
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-1964
Practice Address - Country:US
Practice Address - Phone:904-427-1383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRPT28187183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician