Provider Demographics
NPI:1164187290
Name:EDINBURGH, ELLORINE D
Entity Type:Individual
Prefix:
First Name:ELLORINE
Middle Name:D
Last Name:EDINBURGH
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 1:1522 SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-2965
Mailing Address - Country:US
Mailing Address - Phone:318-230-6192
Mailing Address - Fax:
Practice Address - Street 1:1522 SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-2965
Practice Address - Country:US
Practice Address - Phone:318-230-6192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty