Provider Demographics
NPI:1619475936
Name:DIXON, ELLEN
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:DIXON
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 1:9502 GARDEN WOOD DR APT 421
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76118-4719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9502 GARDEN WOOD DRIVE APT 421
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76118
Practice Address - Country:US
Practice Address - Phone:903-363-4444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-01
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer