Provider Demographics
NPI:1154584191
Name:ELLIS, PATRICIA (RD)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 COURTHOUSE DR NE PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:BOLIVIA
Mailing Address - State:NC
Mailing Address - Zip Code:28422
Mailing Address - Country:US
Mailing Address - Phone:888-428-4429
Mailing Address - Fax:910-253-2379
Practice Address - Street 1:25 COURTHOUSE DR NE
Practice Address - Street 2:
Practice Address - City:BOLIVIA
Practice Address - State:NC
Practice Address - Zip Code:28422
Practice Address - Country:US
Practice Address - Phone:888-428-4429
Practice Address - Fax:910-253-2379
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL001598133N00000X
NC651244133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist