Provider Demographics
NPI:1780987032
Name:ELLISON, MERRI DORETHA
Entity type:Individual
Prefix:
First Name:MERRI
Middle Name:DORETHA
Last Name:ELLISON
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:PO BOX 70365
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36107-0365
Mailing Address - Country:US
Mailing Address - Phone:334-420-5038
Mailing Address - Fax:334-420-0158
Practice Address - Street 1:2350 WASHINGTON PL NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-1070
Practice Address - Country:US
Practice Address - Phone:202-544-7580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-08
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1105095363L00000X
DCNP500021596363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner