Provider Demographics
NPI:1831570787
Name:ELLIS, TANACE
Entity type:Individual
Prefix:
First Name:TANACE
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 1:10100 BAYMEADOWS RD
Mailing Address - Street 2:APT#1504
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-0536
Mailing Address - Country:US
Mailing Address - Phone:904-654-1499
Mailing Address - Fax:
Practice Address - Street 1:10100 BAYMEADOWS RD
Practice Address - Street 2:APT#1504
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-0536
Practice Address - Country:US
Practice Address - Phone:904-654-1499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-16
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3042224Z00000X
FL12888224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant