MEDICARE: MELISSA L 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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1578073722
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA L ELLIS

Provider Business Mailing Address
First Line	:	207 N HWY 59
Second Line	:
City	:	KANSAS
State	:	OK
Zip	:	74347-0000
Country	:	US
Telephone Number	:	918-786-4434
Fax Number	:	918-786-4435

Provider Business Practice Location Address
First Line	:	207 N HWY 59
Second Line	:
City	:	KANSAS
State	:	OK
Zip	:	74347-0000
Country	:	US
Telephone Number	:	918-786-4434
Fax Number	:	918-786-4435

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

Provider Enumeration Date	:	10/02/2017
Last Update Date	:	10/02/2017

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Directions to “ MELISSA L ELLIS ” Practice Location

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