Provider Demographics
NPI:1982275640
Name:ELLIS, ALIVIA
Entity type:Individual
Prefix:
First Name:ALIVIA
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 1:6537 SADDLE BRIDGE DR E
Mailing Address - Street 2:
Mailing Address - City:WHITEHOUSE
Mailing Address - State:OH
Mailing Address - Zip Code:43571-9308
Mailing Address - Country:US
Mailing Address - Phone:419-276-3652
Mailing Address - Fax:
Practice Address - Street 1:6537 SADDLE BRIDGE DR E
Practice Address - Street 2:
Practice Address - City:WHITEHOUSE
Practice Address - State:OH
Practice Address - Zip Code:43571-9308
Practice Address - Country:US
Practice Address - Phone:419-276-3652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-05
Last Update Date:2021-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care