Provider Demographics
NPI:1417791344
Name:CROMER-ELLIS, KEIRRA SHEQUANNA (NUTRITIONIST)
Entity type:Individual
Prefix:
First Name:KEIRRA
Middle Name:SHEQUANNA
Last Name:CROMER-ELLIS
Suffix:
Gender:F
Credentials:NUTRITIONIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 PROSPECT PATH
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-2694
Mailing Address - Country:US
Mailing Address - Phone:470-954-6517
Mailing Address - Fax:
Practice Address - Street 1:44 DARBYS CROSSING DR STE 206H
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-6029
Practice Address - Country:US
Practice Address - Phone:470-954-6517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach