=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154584191
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICIA ELLIS RD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2008
-----------------------------------------------------
Last Update Date | 07/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 COURTHOUSE DR NE
-----------------------------------------------------
City | BOLIVIA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-428-4429
-----------------------------------------------------
Fax | 910-253-2379
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25 COURTHOUSE DR NE PO BOX 9
-----------------------------------------------------
City | BOLIVIA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-428-4429
-----------------------------------------------------
Fax | 910-253-2379
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133N00000X
-----------------------------------------------------
Taxonomy Name | Nutritionist
-----------------------------------------------------
License Number | L001598
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | 651244
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------