Provider Demographics
NPI:1558561910
Name:ELLINGTON, SANDRA LEIGH (MS, RD, LD, CDE)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LEIGH
Last Name:ELLINGTON
Suffix:
Gender:F
Credentials:MS, RD, LD, CDE
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 555
Mailing Address - Street 2:
Mailing Address - City:OWINGSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40360-0555
Mailing Address - Country:US
Mailing Address - Phone:606-674-6396
Mailing Address - Fax:606-674-3071
Practice Address - Street 1:730 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-1444
Practice Address - Country:US
Practice Address - Phone:606-784-8954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0477133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0277206Medicare UPIN