Healthcare Provider Details

I. General information

NPI: 1134844426
Provider Name (Legal Business Name): ELLIS PEDIATRICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2022
Last Update Date: 03/01/2023
Certification Date: 03/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12086 FORT CAROLINE RD STE 401
JACKSONVILLE FL
32225-7640
US

IV. Provider business mailing address

12086 FORT CAROLINE RD STE 401
JACKSONVILLE FL
32225-7640
US

V. Phone/Fax

Practice location:
  • Phone: 904-456-9240
  • Fax:
Mailing address:
  • Phone: 904-456-9240
  • Fax: 904-456-9231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: KENYANITA ELLIS
Title or Position: OWNER/PEDIATRICIAN
Credential: DO
Phone: 904-456-9240