1043124811 NPI number — STEPHANIE RENATE ELLIS LMBT7685

Table of content: STEPHANIE RENATE ELLIS LMBT7685 (NPI 1043124811)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043124811 NPI number — STEPHANIE RENATE ELLIS LMBT7685

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIS
Provider First Name:
STEPHANIE
Provider Middle Name:
RENATE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMBT7685
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:
1043124811
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
255 HORSESHOE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURGAW
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28425-8230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-431-3325
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 E FREMONT ST RM 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURGAW
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28425-5244
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-431-3325
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/29/2026

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: 225700000X , with the licence number:  07685 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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