1023531340 NPI number — MRS. KIMBERLY Y ELLIS

Table of content: MRS. KIMBERLY Y ELLIS (NPI 1023531340)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023531340 NPI number — MRS. KIMBERLY Y ELLIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIS
Provider First Name:
KIMBERLY
Provider Middle Name:
Y
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023531340
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/18/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7365 GRANVILLE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANSFIELD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76063-4647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-657-9165
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7365 GRANVILLE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANSFIELD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76063-4647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-657-9165
Provider Business Practice Location Address Fax Number:
469-657-9165
Provider Enumeration Date:
07/18/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 373H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0 . This is a "NONE" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com