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General NPI Number Information
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NPI Number | 1336215599
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Entity Type | Individual
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Provider Name | SHARON KELLY ELLIS O.D.
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Gender | Female
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Dates
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Enumeration Date | 11/28/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 5370 STONE MOUNTAIN HWY SUITE 700
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City | STONE MOUNTAIN
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State | GA
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Zip | 30087-3581
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Country | US
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Telephone | 770-879-1961
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Fax | 770-879-9872
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Provider Business Mailing Address
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Address Line | 4173 PROVIDENCE LN
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City | TUCKER
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State | GA
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Zip | 30084-2629
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Country | US
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Telephone | 678-937-1622
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Fax | 678-937-1627
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1283
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License Number State | GA
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