Healthcare Provider Details

I. General information

NPI: 1871115493
Provider Name (Legal Business Name): ELLISON ELLISON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2020
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 CENTERVILLE RD STE 4200
TALLAHASSEE FL
32308-4622
US

IV. Provider business mailing address

1405 CENTERVILLE RD STE 4200
TALLAHASSEE FL
32308-4622
US

V. Phone/Fax

Practice location:
  • Phone: 850-848-4628
  • Fax: 850-702-9727
Mailing address:
  • Phone: 850-848-4628
  • Fax: 850-702-9727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME153186
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: