Healthcare Provider Details

I. General information

NPI: 1225686470
Provider Name (Legal Business Name): MAKAYLA A ELLISON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2019
Last Update Date: 08/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3240 STERMER RD
CONWAY AR
72034
US

IV. Provider business mailing address

110 SKYLINE DR
RUSSELLVILLE AR
72801-3362
US

V. Phone/Fax

Practice location:
  • Phone: 501-327-1701
  • Fax:
Mailing address:
  • Phone: 479-968-1298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: