Individual
ELLION PROFITT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
5479 MEMORIAL DR STE 2, STONE MOUNTAIN, GA 30083-3247
(678) 431-6352
Mailing address
3738 WALDROP CREEK CT, DECATUR, GA 30034-6723
(678) 431-6352
Taxonomy
Speciality
Code
Description
License number
State
1744P3200X
Prosthetics Case Management
Primary
CO101834
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
CO101834
SECRETARY OF STATE
GA
Enumeration date
02/19/2018
Last updated
02/19/2018
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