Healthcare Provider Details

I. General information

NPI: 1588894992
Provider Name (Legal Business Name): MS. NIA ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2009
Last Update Date: 07/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53364 CYPRIAN RD
LORANGER LA
70446-2220
US

IV. Provider business mailing address

53364 CYPRIAN RD
LORANGER LA
70446-2220
US

V. Phone/Fax

Practice location:
  • Phone: 985-878-3848
  • Fax: 985-878-1106
Mailing address:
  • Phone: 985-878-3848
  • Fax: 985-878-1106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License NumberSIL 20189
License Number StateLA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: