Healthcare Provider Details

I. General information

NPI: 1548294713
Provider Name (Legal Business Name): ABBY M ELLENBURG PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4223 ORANGE BEACH BLVD SUITE D
ORANGE BEACH AL
36561-3459
US

IV. Provider business mailing address

2652 HAMPTON PARK CIR
FOLEY AL
36535-1130
US

V. Phone/Fax

Practice location:
  • Phone: 251-981-1300
  • Fax: 251-981-1305
Mailing address:
  • Phone: 251-971-6219
  • Fax: 256-350-7757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPTH4586
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: