MEDICARE: CHATAQUA DENEAN ELLISON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374J00000X	Doula		NC

General Provider Information

NPI Number	:	1467125765
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHATAQUA DENEAN ELLISON

Provider Business Mailing Address
First Line	:	9701 TRINITY RD APT H
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-2920
Country	:	US
Telephone Number	:	980-318-0092
Fax Number	:

Provider Business Practice Location Address
First Line	:	9701 TRINITY RD APT H
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-2920
Country	:	US
Telephone Number	:	980-318-0092
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2021
Last Update Date	:	08/03/2021

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Directions to “ CHATAQUA DENEAN ELLISON ” Practice Location

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