Provider Demographics
NPI:1366942047
Name:PROFITT, ELLION
Entity type:Individual
Prefix:
First Name:ELLION
Middle Name:
Last Name:PROFITT
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 1:3738 WALDROP CREEK CT
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-6723
Mailing Address - Country:US
Mailing Address - Phone:678-431-6352
Mailing Address - Fax:
Practice Address - Street 1:5479 MEMORIAL DR STE 2
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3247
Practice Address - Country:US
Practice Address - Phone:678-431-6352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO1018341744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACO101834OtherSECRETARY OF STATE