Provider Demographics
NPI:1831957307
Name:ELLIS, CHARNE
Entity type:Individual
Prefix:
First Name:CHARNE
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 1:1601 HUGUENOT RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-2428
Mailing Address - Country:US
Mailing Address - Phone:804-794-3937
Mailing Address - Fax:804-794-9216
Practice Address - Street 1:1601 HUGUENOT RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-2428
Practice Address - Country:US
Practice Address - Phone:804-794-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-11
Last Update Date:2025-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3889152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program