1376858654 NPI number — ALENA DAVIDA ELLERBROEK MSN,FNP

Table of content: ALENA DAVIDA ELLERBROEK MSN,FNP (NPI 1376858654)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376858654 NPI number — ALENA DAVIDA ELLERBROEK MSN,FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLERBROEK
Provider First Name:
ALENA
Provider Middle Name:
DAVIDA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSN,FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MARTINEZ
Provider Other First Name:
ALENA
Provider Other Middle Name:
DAVIDA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1376858654
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
441 E SAN MARNAN DR
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
WATERLOO
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50702-5900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-234-6000
Provider Business Mailing Address Fax Number:
319-234-6001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
441 E SAN MARNAN DR
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
WATERLOO
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50702-5900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-234-6000
Provider Business Practice Location Address Fax Number:
319-234-6001
Provider Enumeration Date:
08/11/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  A123879 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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