Healthcare Provider Details

I. General information

NPI: 1063053346
Provider Name (Legal Business Name): ELISHEVA ELLENBERG FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2019
Last Update Date: 10/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CHILDREN'S SPECIALTY CENTER 3950 BEAUBIEN STREET - 3RD FL
DETROIT MI
48201-2119
US

IV. Provider business mailing address

UNIVERSITY PEDIATRICIANS 4201 ST. ANTOINE - UHC 5D MAILBOX 226
DETROIT MI
48201-2153
US

V. Phone/Fax

Practice location:
  • Phone: 313-832-9330
  • Fax:
Mailing address:
  • Phone: 313-745-4405
  • Fax: 313-966-0665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704312142
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: