1548251275 NPI number — EILEEN T MCELLIGOTT FNP

Table of content: EILEEN T MCELLIGOTT FNP (NPI 1548251275)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548251275 NPI number — EILEEN T MCELLIGOTT FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCELLIGOTT
Provider First Name:
EILEEN
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548251275
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/31/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
620 NW 11TH ST STE M201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HERMISTON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97838-6941
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-289-4118
Provider Business Mailing Address Fax Number:
541-667-3484

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 NW 11TH ST STE E37
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HERMISTON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97838-8604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-567-5305
Provider Business Practice Location Address Fax Number:
541-667-3487
Provider Enumeration Date:
11/02/2005

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:  088007207N1 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 213051 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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