1811106222 NPI number — ELLEN M DETHLOFF NP

Table of content: ELLEN M DETHLOFF NP (NPI 1811106222)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811106222 NPI number — ELLEN M DETHLOFF NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DETHLOFF
Provider First Name:
ELLEN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GUNDERSON
Provider Other First Name:
ELLEN
Provider Other Middle Name:
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:
1811106222
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/14/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
303 N CLYDE MORRIS BLVD # 8E
Provider Second Line Business Mailing Address:
COORDINATOR EDUCATION-CLINICAL AFFILIATES
Provider Business Mailing Address City Name:
DAYTONA BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32114-2709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-425-5921
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
303 N CLYDE MORRIS BLVD # 8E
Provider Second Line Business Practice Location Address:
COORDINATOR EDUCATION-CLINICAL AFFILIATES
Provider Business Practice Location Address City Name:
DAYTONA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32114-2709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-425-5800
Provider Business Practice Location Address Fax Number:
386-425-5801
Provider Enumeration Date:
05/22/2007

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: 363L00000X , with the licence number:  300456 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: ARNP 9373273 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 010868200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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