Provider Demographics
NPI:1215418157
Name:ELLEFSON, DONALD EDMUND (LPN)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:EDMUND
Last Name:ELLEFSON
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 COUNTY ROAD 4711
Mailing Address - Street 2:
Mailing Address - City:KEMPNER
Mailing Address - State:TX
Mailing Address - Zip Code:76539-5901
Mailing Address - Country:US
Mailing Address - Phone:402-452-8188
Mailing Address - Fax:
Practice Address - Street 1:4204 TROPICANA DR
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-4592
Practice Address - Country:US
Practice Address - Phone:254-338-3621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE21193164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse