Healthcare Provider Details

I. General information

NPI: 1275299109
Provider Name (Legal Business Name): SADIE MAE ELLENBERG BSN, RN, CNOR, RNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2021
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 CONEY ST W
PERHAM MN
56573-2102
US

IV. Provider business mailing address

1000 CONEY ST W
PERHAM MN
56573-2102
US

V. Phone/Fax

Practice location:
  • Phone: 218-347-1498
  • Fax:
Mailing address:
  • Phone: 218-347-1498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberCEO11471
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: