Provider Demographics
NPI:1144314139
Name:BENNETT, ELLIE MARIE (DC)
Entity type:Individual
Prefix:
First Name:ELLIE
Middle Name:MARIE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:ELLIE
Other - Middle Name:MARIE
Other - Last Name:SCHNITZLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3109 YORK AVE N
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-5418
Mailing Address - Country:US
Mailing Address - Phone:763-287-0551
Mailing Address - Fax:
Practice Address - Street 1:4080 W BROADWAY AVE
Practice Address - Street 2:STE. 218
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-5604
Practice Address - Country:US
Practice Address - Phone:763-535-4342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4852111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
154H1BEOtherBLUE CROSS BLUE SHIELD