MEDICARE: SUZANNE ELLIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	146N00000X	Basic Emergency Medical Technician	0172435	OH

General Provider Information

NPI Number	:	1164978466
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUZANNE ELLIS

Provider Business Mailing Address
First Line	:	114 SOUTH ST
Second Line	:
City	:	QUINCY
State	:	OH
Zip	:	43343
Country	:	US
Telephone Number	:	937-538-7619
Fax Number	:

Provider Business Practice Location Address
First Line	:	114 SOUTH ST
Second Line	:
City	:	QUINCY
State	:	OH
Zip	:	43343
Country	:	US
Telephone Number	:	937-538-7619
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2016
Last Update Date	:	08/28/2016

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Directions to “ SUZANNE ELLIS ” Practice Location

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