Provider Demographics
NPI:1992297394
Name:ELLIS, ALISA RUTH
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:RUTH
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 1:2320 COURT NORTH DR
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-8147
Mailing Address - Country:US
Mailing Address - Phone:631-424-0842
Mailing Address - Fax:
Practice Address - Street 1:2320 COURT NORTH DR
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-8147
Practice Address - Country:US
Practice Address - Phone:631-424-0842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY449280174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist