Provider Demographics
NPI:1124798152
Name:ELLIS, ALEISHA SHONTE (LPN)
Entity type:Individual
Prefix:
First Name:ALEISHA
Middle Name:SHONTE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1627 DONOVANS RDG NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-7693
Mailing Address - Country:US
Mailing Address - Phone:404-983-2484
Mailing Address - Fax:
Practice Address - Street 1:1627 DONOVANS RDG NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-7693
Practice Address - Country:US
Practice Address - Phone:404-983-2484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN074894164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse