Healthcare Provider Details

I. General information

NPI: 1265033302
Provider Name (Legal Business Name): TIERRA LASHAY ELLIS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2020
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 WINONA CT
DENVER CO
80204-1138
US

IV. Provider business mailing address

PO BOX 140574
DENVER CO
80214-0574
US

V. Phone/Fax

Practice location:
  • Phone: 720-403-6669
  • Fax:
Mailing address:
  • Phone: 720-689-3301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: