Individual
STACEY ELLIS
Active
Sole proprietor
Provider details
NPI number
Gender
F
Contact information
Practice address
9005 TUDOR LN, MANASSAS, VA 20110-5754
(703) 257-8500
Mailing address
110 TOWNSHIP CT, STEPHENS CITY, VA 22655-2962
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
0126000571
VA
Other
Enumeration date
04/25/2006
Last updated
07/08/2007
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