Healthcare Provider Details

I. General information

NPI: 1346818085
Provider Name (Legal Business Name): MISTY ELLISON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2021
Last Update Date: 06/17/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 BROAD ST STE 101
SUMMERSVILLE WV
26651-1708
US

IV. Provider business mailing address

5638 LEGATE DR
ROANOKE VA
24019-3354
US

V. Phone/Fax

Practice location:
  • Phone: 304-872-9531
  • Fax:
Mailing address:
  • Phone: 540-815-0988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: