Provider Demographics
NPI:1285834275
Name:ELLENBERG, MELANIE
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:ELLENBERG
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 210884
Mailing Address - Street 2:
Mailing Address - City:AUKE BAY
Mailing Address - State:AK
Mailing Address - Zip Code:99821-0884
Mailing Address - Country:US
Mailing Address - Phone:907-789-3941
Mailing Address - Fax:907-790-3942
Practice Address - Street 1:3869 CAROLINE ST
Practice Address - Street 2:SUITE A
Practice Address - City:AUKE BAY
Practice Address - State:AK
Practice Address - Zip Code:99821-0884
Practice Address - Country:US
Practice Address - Phone:907-789-3941
Practice Address - Fax:907-790-3942
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator