Provider Demographics
NPI:1881094845
Name:ELLINGTON, JEANITA
Entity type:Individual
Prefix:
First Name:JEANITA
Middle Name:
Last Name:ELLINGTON
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 1:23848 LONE PINE DR
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-2947
Mailing Address - Country:US
Mailing Address - Phone:951-490-3659
Mailing Address - Fax:
Practice Address - Street 1:23848 LONE PINE DR
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92557-2947
Practice Address - Country:US
Practice Address - Phone:951-490-3659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-27
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 208434164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse