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General NPI Number Information
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NPI Number | 1548064769
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Entity Type | Individual
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Provider Name | MRS. SHANDA LATRESE ELLIS
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Gender |
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Dates
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Enumeration Date | 04/04/2025
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Last Update Date | 04/04/2025
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Provider Practice Location Address
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Address Line | 198 PARKWAY CIR
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City | WEST MONROE
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State | LA
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Zip | 71292-8032
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Country | US
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Telephone | 318-574-0098
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Fax |
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Provider Business Mailing Address
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Address Line | 29 FAIR OAKS DR
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City | MONROE
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State | LA
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Zip | 71203-2735
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Country | US
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Telephone | 318-307-6179
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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 | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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