Provider Demographics
NPI:1982441507
Name:ELLIS, PATRICIA A
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:A
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 1:21494 AVON LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-7104
Mailing Address - Country:US
Mailing Address - Phone:616-264-8156
Mailing Address - Fax:
Practice Address - Street 1:21494 AVON LN
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-7104
Practice Address - Country:US
Practice Address - Phone:616-264-8156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home