Basic Information
| Provider Information | |||||||||
| NPI: | 1154769214 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLISON | ||||||||
| FirstName: | ANGELIQUE | ||||||||
| MiddleName: | NIKKOL-TELYCENAS | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26901 BEAUMONT BLVD STE 3D | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480333849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9475221863 | ||||||||
| FaxNumber: | 9475220307 | ||||||||
| Practice Location | |||||||||
| Address1: | 5400 FORT ST STE 250 | ||||||||
| Address2: | |||||||||
| City: | TRENTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481834630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346422480 | ||||||||
| FaxNumber: | 7346422475 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2013 | ||||||||
| LastUpdateDate: | 10/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 5101020652 | MI | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.