Provider Demographics
NPI:1528580446
Name:WRIGHT, ELLY (MAT, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:ELLY
Middle Name:
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:MAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 MAURICE AVE APT 309A
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-6081
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-2190
Practice Address - Country:US
Practice Address - Phone:970-556-4281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-12
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
KYAT17692255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer