Provider Demographics
NPI:1104661107
Name:ELLIS, AQUANITA SHERETTA
Entity type:Individual
Prefix:
First Name:AQUANITA
Middle Name:SHERETTA
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 1:1007 SAMFORD CT APT B
Mailing Address - Street 2:
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-9782
Mailing Address - Country:US
Mailing Address - Phone:706-302-9291
Mailing Address - Fax:
Practice Address - Street 1:808 20TH ST
Practice Address - Street 2:
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36867-4525
Practice Address - Country:US
Practice Address - Phone:706-302-9291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-01
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive Care
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Multi-Specialty