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General NPI Number Information
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NPI Number | 1134844426
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Entity Type | Organization
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Legal Business Name | ELLIS PEDIATRICS, PLLC
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Dates
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Enumeration Date | 10/10/2022
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Last Update Date | 03/01/2023
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Provider Practice Location Address
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Address Line | 12086 FORT CAROLINE RD STE 401
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City | JACKSONVILLE
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State | FL
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Zip | 32225-7640
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Country | US
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Telephone | 904-456-9240
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Fax |
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Provider Business Mailing Address
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Address Line | 12086 FORT CAROLINE RD STE 401
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City | JACKSONVILLE
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State | FL
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Zip | 32225-7640
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Country | US
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Telephone | 904-456-9240
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Fax | 904-456-9231
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Authorized Official
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Title or Position | OWNER/PEDIATRICIAN
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Name | KENYANITA ELLIS
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Credential | DO
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Telephone | 904-456-9240
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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