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General NPI Number Information
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NPI Number | 1346685575
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Entity Type | Individual
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Provider Name | KATHLEEN MARIE ELLIS LPTA
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Gender | Female
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Dates
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Enumeration Date | 05/01/2013
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Last Update Date | 05/01/2013
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Provider Practice Location Address
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Address Line | 512 BEACH ST
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City | FENTON
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State | MI
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Zip | 48430-3122
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Country | US
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Telephone | 810-629-4117
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Fax |
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Provider Business Mailing Address
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Address Line | 11182 E RICHFIELD RD
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City | DAVISON
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State | MI
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Zip | 48423-8517
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Country | US
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Telephone | 810-252-9888
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Fax |
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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 | 313M00000X
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Taxonomy Name | Nursing Facility/Intermediate Care Facility
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License Number | 5502001225
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License Number State | MI
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