Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LN0000X | Nurse Practitioner - Neonatal | RN154735 | GA |
NPI | 1043477078 |
---|---|
Provider Name | Mrs. Kyndra Lenee Ellis |
First Address | Stockbridge, GA 30281-7716 |
Second Address | Stockbridge, GA 30281-7716 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/05/2008 |
Last Update Date | 31/10/2016 |