Provider Demographics
NPI:1548815590
Name:ELLENBERGER, RITAJO
Entity type:Individual
Prefix:
First Name:RITAJO
Middle Name:
Last Name:ELLENBERGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 186
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-0186
Mailing Address - Country:US
Mailing Address - Phone:320-808-8054
Mailing Address - Fax:
Practice Address - Street 1:220 OAK STREET NORTH
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308
Practice Address - Country:US
Practice Address - Phone:320-808-8054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43283251G00000X, 164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
No251G00000XAgenciesHospice Care, Community BasedGroup - Single Specialty