MEDICARE: DR. KENYANITA ELLIS D.O.

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	208000000X	Pediatrics Physician	OS16790	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841727716
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENYANITA ELLIS D.O.

Provider Business Mailing Address
First Line	:	12086 FORT CAROLINE RD STE 401
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32225-7640
Country	:	US
Telephone Number	:	904-456-9240
Fax Number	:	904-456-9231

Provider Business Practice Location Address
First Line	:	12086 FORT CAROLINE RD STE 401
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32225-7640
Country	:	US
Telephone Number	:	904-456-9240
Fax Number	:	904-456-9231

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

Provider Enumeration Date	:	05/22/2017
Last Update Date	:	03/01/2023

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