MEDICARE: MERRI DORETHA 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	363L00000X	Nurse Practitioner	1105095	AL
2	363LF0000X	Family Nurse Practitioner	NP500021596	DC

General Provider Information

NPI Number	:	1780987032
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MERRI DORETHA ELLISON

Provider Business Mailing Address
First Line	:	PO BOX 70365
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36107-0365
Country	:	US
Telephone Number	:	334-420-5038
Fax Number	:	334-420-0158

Provider Business Practice Location Address
First Line	:	2350 WASHINGTON PL NE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20018-1070
Country	:	US
Telephone Number	:	202-544-7580
Fax Number	:

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

Provider Enumeration Date	:	12/08/2010
Last Update Date	:	01/21/2025

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Directions to “ MERRI DORETHA ELLISON ” Practice Location

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