Provider Demographics
NPI:1104226109
Name:ELLIS, KELLY S (ATC, LAT, PTA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:S
Last Name:ELLIS
Suffix:
Gender:F
Credentials:ATC, LAT, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3276 NORTHSIDE PKWY NW UNIT 4410
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-2344
Mailing Address - Country:US
Mailing Address - Phone:678-525-6256
Mailing Address - Fax:
Practice Address - Street 1:3276 NORTHSIDE PKWY NW UNIT 4410
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-2344
Practice Address - Country:US
Practice Address - Phone:678-525-6256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-26
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0027012255A2300X
FL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program