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General NPI Number Information
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NPI Number | 1568867430
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Entity Type | Individual
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Provider Name | SHANNON M ELLIS PTA
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Gender | Female
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Dates
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Enumeration Date | 11/04/2014
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Last Update Date | 11/04/2014
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Provider Practice Location Address
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Address Line | 5775 OLD WINDER HWY
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City | BRASELTON
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State | GA
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Zip | 30517-1603
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Country | US
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Telephone | 678-866-4104
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Fax |
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Provider Business Mailing Address
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Address Line | 3576 PHOENIX COVE DR
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City | GAINESVILLE
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State | GA
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Zip | 30506-4669
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Country | US
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Telephone | 574-286-2559
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | PTA002735
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License Number State | GA
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