Provider Demographics
NPI:1417584418
Name:ELLENBERGER, ASHLEY DETZNER (MD)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:DETZNER
Last Name:ELLENBERGER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:ALEXANDRA
Other - Last Name:DETZNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:8414 NAAB RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1972
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 UNIVERSITY BLVD RM 641
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5149
Practice Address - Country:US
Practice Address - Phone:317-944-1816
Practice Address - Fax:317-948-2803
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program