Provider Demographics
NPI:1689446254
Name:ELLINGSON, VICTORIA JOY
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:JOY
Last Name:ELLINGSON
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 1:12611 DRIFTWOOD COURT
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-8661
Mailing Address - Country:US
Mailing Address - Phone:952-423-6180
Mailing Address - Fax:
Practice Address - Street 1:12611 DRIFTWOOD COURT
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-8661
Practice Address - Country:US
Practice Address - Phone:952-423-6180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNQ7071439798142255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer