Healthcare Provider Details

I. General information

NPI: 1780100776
Provider Name (Legal Business Name): BEVIN LYLE ELLENBERG CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2017
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 HIGHWAY 78 E STE A
JASPER AL
35501-8908
US

IV. Provider business mailing address

PO BOX 18428
HUNTSVILLE AL
35804-8428
US

V. Phone/Fax

Practice location:
  • Phone: 205-387-0333
  • Fax: 256-534-2605
Mailing address:
  • Phone: 256-705-4224
  • Fax: 256-705-4135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1-140234
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: