Healthcare Provider Details

I. General information

NPI: 1134570369
Provider Name (Legal Business Name): ELLEN HEUBACH ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2016
Last Update Date: 11/01/2021
Certification Date: 10/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

659 NE HWY 19 UNIT 1
CRYSTAL RIVER FL
34429
US

IV. Provider business mailing address

PO BOX 2066
LECANTO FL
34460-2066
US

V. Phone/Fax

Practice location:
  • Phone: 352-563-0911
  • Fax:
Mailing address:
  • Phone: 352-563-0931
  • Fax: 352-563-0935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberARNP9186834
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9186834
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: