Provider Demographics
NPI:1871533570
Name:ELLIS, JANENNE E (PT)
Entity type:Individual
Prefix:
First Name:JANENNE
Middle Name:E
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10000 BEACH DR SW UNIT 9
Mailing Address - Street 2:
Mailing Address - City:CALABASH
Mailing Address - State:NC
Mailing Address - Zip Code:28467-2856
Mailing Address - Country:US
Mailing Address - Phone:910-579-2745
Mailing Address - Fax:910-579-2847
Practice Address - Street 1:10000 BEACH DR SW UNIT 9
Practice Address - Street 2:
Practice Address - City:CALABASH
Practice Address - State:NC
Practice Address - Zip Code:28467-2856
Practice Address - Country:US
Practice Address - Phone:910-579-2745
Practice Address - Fax:910-579-2847
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP2997225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC501889202OtherTRICARE
NC1180992OtherFIRSTHEALTH/MAILHANDLERS
NC1131HOtherBLUE CROSS BLUE SHIELD NC
NC125357800OtherUS DEPART OF LABOR
NCE2499OtherMEDCOST PROVIDER #
NC125357800OtherUS DEPART OF LABOR