Provider Demographics
NPI:1053016329
Name:ELLISON, MARY ELIZABETH
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:ELLISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8119 SOUTHWOOD DR APT 104
Mailing Address - Street 2:
Mailing Address - City:GARRETTSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44231-1143
Mailing Address - Country:US
Mailing Address - Phone:330-977-0115
Mailing Address - Fax:
Practice Address - Street 1:8119 SOUTHWOOD DR APT 104
Practice Address - Street 2:
Practice Address - City:GARRETTSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44231-1143
Practice Address - Country:US
Practice Address - Phone:330-977-0115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No347C00000XTransportation ServicesPrivate Vehicle