Provider Demographics
NPI:1699424366
Name:ELLIS, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:ELLIS
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 1:3004 HEATH AVE APT 33
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-5962
Mailing Address - Country:US
Mailing Address - Phone:347-786-4058
Mailing Address - Fax:
Practice Address - Street 1:135 W 50TH ST FL 6
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10020-1201
Practice Address - Country:US
Practice Address - Phone:212-582-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-21
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY330768990175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist