Provider Demographics
NPI:1548064769
Name:ELLIS, SHANDA LATRESE
Entity type:Individual
Prefix:MRS
First Name:SHANDA
Middle Name:LATRESE
Last Name:ELLIS
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:SHANDA
Other - Middle Name:LATRESE
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:29 FAIR OAKS DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-2735
Mailing Address - Country:US
Mailing Address - Phone:318-307-6179
Mailing Address - Fax:
Practice Address - Street 1:198 PARKWAY CIR
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71292-8032
Practice Address - Country:US
Practice Address - Phone:318-574-0098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-04
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator