Provider Demographics
NPI:1912406620
Name:ELLIS, ANGELA C (PT, MPT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:C
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PT, MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5204 MCMANUS DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-7773
Mailing Address - Country:US
Mailing Address - Phone:540-710-6602
Mailing Address - Fax:
Practice Address - Street 1:31 STAFFORD AVE
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-7246
Practice Address - Country:US
Practice Address - Phone:540-658-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-08
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23052021332251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics