Healthcare Provider Details

I. General information

NPI: 1376450973
Provider Name (Legal Business Name): BRIANA ELLISON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3928 WILMONT AVE NW
ROANOKE VA
24017-4824
US

IV. Provider business mailing address

3747 ROLLING HILL AVE NW
ROANOKE VA
24017-6501
US

V. Phone/Fax

Practice location:
  • Phone: 540-566-8538
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number0002097054
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: