=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437964384
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ABIGAIL ELLIFSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2025
-----------------------------------------------------
Last Update Date | 12/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | W346N5312 ELM AVE
-----------------------------------------------------
City | OKAUCHEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53069-9756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-793-3550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | W346N5312 ELM AVE
-----------------------------------------------------
City | OKAUCHEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53069-9756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-793-3550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------