Provider Demographics
NPI:1215270889
Name:ELLIS-BURNETT, KANDACE MICHAELE (BA)
Entity type:Individual
Prefix:MS
First Name:KANDACE
Middle Name:MICHAELE
Last Name:ELLIS-BURNETT
Suffix:
Gender:F
Credentials:BA
Other - Prefix:MISS
Other - First Name:KANDACE
Other - Middle Name:MICHAELE
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BA
Mailing Address - Street 1:8910 CLAIREMONT MESA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1104
Mailing Address - Country:US
Mailing Address - Phone:858-514-5100
Mailing Address - Fax:858-514-5190
Practice Address - Street 1:3148 MIDWAY DR STE 113
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4539
Practice Address - Country:US
Practice Address - Phone:619-363-0853
Practice Address - Fax:619-362-9905
Is Sole Proprietor?:No
Enumeration Date:2013-04-02
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist