Provider Demographics
NPI:1992469142
Name:ELLIS, LAURA GAINES-BEY (LAC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:GAINES-BEY
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43308 N 44TH DR
Mailing Address - Street 2:
Mailing Address - City:NEW RIVER
Mailing Address - State:AZ
Mailing Address - Zip Code:85087-5921
Mailing Address - Country:US
Mailing Address - Phone:623-977-2304
Mailing Address - Fax:
Practice Address - Street 1:42101 N 41ST DR STE 152
Practice Address - Street 2:
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-3819
Practice Address - Country:US
Practice Address - Phone:602-877-3045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ010045171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist