Provider Demographics
NPI:1962477281
Name:ELLIS, PERCITA LOREN (MD)
Entity type:Individual
Prefix:DR
First Name:PERCITA
Middle Name:LOREN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 GROUSE RUN RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:24450-2252
Mailing Address - Country:US
Mailing Address - Phone:540-463-1006
Mailing Address - Fax:540-463-2003
Practice Address - Street 1:6 GROUSE RUN RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:VA
Practice Address - Zip Code:24450-2252
Practice Address - Country:US
Practice Address - Phone:540-463-1006
Practice Address - Fax:540-463-2003
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101231232208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics