Healthcare Provider Details

I. General information

NPI: 1740195585
Provider Name (Legal Business Name): MAYA ELLIS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13838 S 46TH PL
PHOENIX AZ
85044-7800
US

IV. Provider business mailing address

4630 S LAKESHORE DR
TEMPE AZ
85282-7164
US

V. Phone/Fax

Practice location:
  • Phone: 520-656-9724
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: