Healthcare Provider Details

I. General information

NPI: 1780240218
Provider Name (Legal Business Name): ELLEN MIDDLETON HENDRY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2019
Last Update Date: 04/03/2023
Certification Date: 04/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 NW 76TH DR STE A
GAINESVILLE FL
32607-6663
US

IV. Provider business mailing address

350 NW 76TH DR STE A
GAINESVILLE FL
32607-6663
US

V. Phone/Fax

Practice location:
  • Phone: 352-332-4051
  • Fax: 352-332-2966
Mailing address:
  • Phone: 352-332-4051
  • Fax: 352-332-2966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberPA9112395
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: