Healthcare Provider Details

I. General information

NPI: 1447797444
Provider Name (Legal Business Name): LESHA LORETTA ELLISON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2017
Last Update Date: 06/23/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2004 CUMBERLAND AVE STE 100
MIDDLESBORO KY
40965
US

IV. Provider business mailing address

2004 CUMBERLAND AVE STE 100
MIDDLESBORO KY
40965-1385
US

V. Phone/Fax

Practice location:
  • Phone: 606-248-3015
  • Fax: 606-248-3024
Mailing address:
  • Phone: 606-248-3015
  • Fax: 606-248-3024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTC781
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: