Healthcare Provider Details

I. General information

NPI: 1780363820
Provider Name (Legal Business Name): GAIL LYNN ELLIS CPSS/ FCPSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2023
Last Update Date: 07/17/2023
Certification Date: 07/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1629 MADISON AVE
COVINGTON KY
41011-3317
US

IV. Provider business mailing address

122 PINEHURST DR APT 4
FLORENCE KY
41042-2728
US

V. Phone/Fax

Practice location:
  • Phone: 859-814-8022
  • Fax:
Mailing address:
  • Phone: 859-652-4550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: