Provider Demographics
NPI:1669710786
Name:ELLISON, ERIN
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:ELLISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 GRADY WHITTON RD
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:GA
Mailing Address - Zip Code:30110-3573
Mailing Address - Country:US
Mailing Address - Phone:404-697-9529
Mailing Address - Fax:
Practice Address - Street 1:222 GORDON ST
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:GA
Practice Address - Zip Code:30110-1519
Practice Address - Country:US
Practice Address - Phone:770-537-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-24
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN198477363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1861915647OtherGROUP NPI