Provider Demographics
NPI:1578110300
Name:BALLENTINE, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BALLENTINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:783 MILLIGAN SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:STEWART
Mailing Address - State:MS
Mailing Address - Zip Code:39767-9429
Mailing Address - Country:US
Mailing Address - Phone:662-312-0435
Mailing Address - Fax:
Practice Address - Street 1:783 MILLIGAN SPRINGS ROAD
Practice Address - Street 2:
Practice Address - City:STEWART
Practice Address - State:MS
Practice Address - Zip Code:39767
Practice Address - Country:US
Practice Address - Phone:662-312-0435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-26
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider