Provider Demographics
NPI:1295389831
Name:ELLENBERGER, KATHLEEN MARY (RN, BSN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARY
Last Name:ELLENBERGER
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8672 COAL HILL RD
Mailing Address - Street 2:
Mailing Address - City:LUTHERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15848-4914
Mailing Address - Country:US
Mailing Address - Phone:814-591-1314
Mailing Address - Fax:
Practice Address - Street 1:100 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1440
Practice Address - Country:US
Practice Address - Phone:814-375-7751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN265951L163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health