Provider Demographics
NPI:1427127018
Name:ELLIS GILMER, MALINDA ELIZABETH (RN CEO)
Entity type:Individual
Prefix:MRS
First Name:MALINDA
Middle Name:ELIZABETH
Last Name:ELLIS GILMER
Suffix:
Gender:F
Credentials:RN CEO
Other - Prefix:MRS
Other - First Name:LINDA
Other - Middle Name:
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN CEO
Mailing Address - Street 1:PO BOX 102
Mailing Address - Street 2:32 UNDERWOOD ST
Mailing Address - City:SEBASTOPOL
Mailing Address - State:MS
Mailing Address - Zip Code:39359
Mailing Address - Country:US
Mailing Address - Phone:601-625-7840
Mailing Address - Fax:601-625-7848
Practice Address - Street 1:32 UNDERWOOD ST
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:MS
Practice Address - Zip Code:39359
Practice Address - Country:US
Practice Address - Phone:601-625-7840
Practice Address - Fax:601-625-7848
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR799883163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS070221OtherBCBS OF MS
MS7976082Medicaid
MS070221OtherBCBS OF MS