Healthcare Provider Details

I. General information

NPI: 1598110017
Provider Name (Legal Business Name): BETH ELLENBERGER N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2016
Last Update Date: 12/27/2019
Certification Date: 12/27/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 TOWN CENTER PLZ STE G130
WEST SACRAMENTO CA
95691-5058
US

IV. Provider business mailing address

PO BOX 255228
SACRAMENTO CA
95865-5228
US

V. Phone/Fax

Practice location:
  • Phone: 916-887-7471
  • Fax: 916-887-7480
Mailing address:
  • Phone: 866-681-0736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95003991
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: