Provider Demographics
NPI:1548294713
Name:ELLENBURG, ABBY M (PT)
Entity type:Individual
Prefix:
First Name:ABBY
Middle Name:M
Last Name:ELLENBURG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2652 HAMPTON PARK CIR
Mailing Address - Street 2:
Mailing Address - City:FOLEY
Mailing Address - State:AL
Mailing Address - Zip Code:36535-1130
Mailing Address - Country:US
Mailing Address - Phone:251-971-6219
Mailing Address - Fax:256-350-7757
Practice Address - Street 1:4223 ORANGE BEACH BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:ORANGE BEACH
Practice Address - State:AL
Practice Address - Zip Code:36561-3459
Practice Address - Country:US
Practice Address - Phone:251-981-1300
Practice Address - Fax:251-981-1305
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH4586174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51002181OtherBCBS