Provider Demographics
NPI:1194409110
Name:HERRON, ELLEXUS (LPN)
Entity type:Individual
Prefix:
First Name:ELLEXUS
Middle Name:
Last Name:HERRON
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 1:44060 ELM DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-1186
Mailing Address - Country:US
Mailing Address - Phone:586-822-0062
Mailing Address - Fax:
Practice Address - Street 1:44060 ELM DR
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-1186
Practice Address - Country:US
Practice Address - Phone:586-822-0062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703125527164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse