Provider Demographics
NPI:1598110017
Name:ELLENBERGER, BETH (NP)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:ELLENBERGER
Suffix:
Gender:F
Credentials:NP
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 255228
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95865-5228
Mailing Address - Country:US
Mailing Address - Phone:866-681-0736
Mailing Address - Fax:
Practice Address - Street 1:2055 TOWN CENTER PLZ STE G130
Practice Address - Street 2:
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95691-5058
Practice Address - Country:US
Practice Address - Phone:916-887-7471
Practice Address - Fax:916-887-7480
Is Sole Proprietor?:No
Enumeration Date:2016-05-03
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95003991363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily