Provider Demographics
NPI:1982409470
Name:ELLIS, BRENDA
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:JUMPING BRANCH
Mailing Address - State:WV
Mailing Address - Zip Code:25969-6053
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:281 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:OAK HILL
Practice Address - State:WV
Practice Address - Zip Code:25901-3475
Practice Address - Country:US
Practice Address - Phone:304-465-3302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-18
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant