Healthcare Provider Details

I. General information

NPI: 1821603606
Provider Name (Legal Business Name): MISS SHERENDA LASHAWN ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1058 WEDGEWOOD CT
CONYERS GA
30012-7120
US

IV. Provider business mailing address

4351 HUGH HOWELL RD STE 1179
TUCKER GA
30084-4721
US

V. Phone/Fax

Practice location:
  • Phone: 404-453-7777
  • Fax:
Mailing address:
  • Phone: 404-453-7777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171WV0202X
TaxonomyVehicle Modifications Contractor
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number9Y6C9J8J7
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: