Provider Demographics
NPI:1346212172
Name:STANBACH, ELLEN M (FNP)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:M
Last Name:STANBACH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:ELLEN
Other - Middle Name:M
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:6 SPYGLASS CT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29609-6944
Mailing Address - Country:US
Mailing Address - Phone:864-292-6028
Mailing Address - Fax:
Practice Address - Street 1:404 MEMORIAL DRIVE EXT
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29651-1818
Practice Address - Country:US
Practice Address - Phone:864-877-4442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC69625363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ15212Medicare UPIN