Provider Demographics
NPI:1326429432
Name:ELLIS- SLAUGHTER, KEYONNA
Entity type:Individual
Prefix:
First Name:KEYONNA
Middle Name:
Last Name:ELLIS- SLAUGHTER
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 1:843 PARKMAN RD NW
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44485-4578
Mailing Address - Country:US
Mailing Address - Phone:234-283-6606
Mailing Address - Fax:
Practice Address - Street 1:843 PARKMAN RD NW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44485-4578
Practice Address - Country:US
Practice Address - Phone:234-283-6606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-15
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TM1800X, 3747P1801X, 376K00000X, 251E00000X
OH401780290815374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome Health
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
No376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCS1607000200Medicaid