Provider Demographics
NPI:1609289214
Name:IGL, ELLEN
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:IGL
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:N8053 HWY 33
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-9762
Mailing Address - Country:US
Mailing Address - Phone:920-885-4144
Mailing Address - Fax:
Practice Address - Street 1:N8053 HWY 33
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-9762
Practice Address - Country:US
Practice Address - Phone:920-885-4144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-11
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care