Healthcare Provider Details

I. General information

NPI: 1679278949
Provider Name (Legal Business Name): ELICIA HOMECARE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2023
Last Update Date: 09/26/2025
Certification Date: 09/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7100 NORTHLAND CIR N STE 123
BROOKLYN PARK MN
55428-1500
US

IV. Provider business mailing address

7100 NORTHLAND CIR N STE 123
BROOKLYN PARK MN
55428-1500
US

V. Phone/Fax

Practice location:
  • Phone: 612-709-3880
  • Fax: 612-454-2583
Mailing address:
  • Phone: 612-709-3880
  • Fax: 612-454-2583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State

VIII. Authorized Official

Name: ANGELLE CLERMONT KANNEH
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 612-709-3880