Healthcare Provider Details

I. General information

NPI: 1285278424
Provider Name (Legal Business Name): TANYELL ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2019
Last Update Date: 04/08/2020
Certification Date: 04/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 BELLE CHASSE HWY
GRETNA LA
70053-6651
US

IV. Provider business mailing address

2100 BELLE CHASSE HIGHWAY
GRETNA LA
70053
US

V. Phone/Fax

Practice location:
  • Phone: 504-367-6630
  • Fax:
Mailing address:
  • Phone: 504-493-9406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number15430
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: