Healthcare Provider Details

I. General information

NPI: 1376452318
Provider Name (Legal Business Name): CAROLINA ELLERBROCK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

965 S GROVE ST
REDLANDS CA
92374-5466
US

IV. Provider business mailing address

965 S GROVE ST
REDLANDS CA
92374-5466
US

V. Phone/Fax

Practice location:
  • Phone: 733-641-1811
  • Fax:
Mailing address:
  • Phone: 733-641-1811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95241139
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: