Provider Demographics
NPI:1245801851
Name:HIBBERTS, ELLEN CHRISTINE (PA)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:CHRISTINE
Last Name:HIBBERTS
Suffix:
Gender:F
Credentials:PA
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 744786
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-4786
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 VILLAGE HARBOR DR STE 104
Practice Address - Street 2:
Practice Address - City:LAKE WYLIE
Practice Address - State:SC
Practice Address - Zip Code:29710-9276
Practice Address - Country:US
Practice Address - Phone:803-831-6859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical