1689186363 NPI number — JOYCELYNN YVONNE GLOVER ELLISON

Table of content: JOYCELYNN YVONNE GLOVER ELLISON (NPI 1689186363)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689186363 NPI number — JOYCELYNN YVONNE GLOVER ELLISON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLOVER ELLISON
Provider First Name:
JOYCELYNN
Provider Middle Name:
YVONNE
Provider Name Prefix Text:
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:
GLOVER
Provider Other First Name:
JOYCELYNN
Provider Other Middle Name:
YVONNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA, TLLP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1689186363
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
106 CHEROKEE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PONTIAC
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48341-1504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-396-8061
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
718 OAK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLINT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48503-2614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-233-8815
Provider Business Practice Location Address Fax Number:
810-833-8812
Provider Enumeration Date:
11/02/2017

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: 103TC0700X , with the licence number:  6301017251 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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