Provider Demographics
NPI:1790058725
Name:ELLINGER, SCOTT MATTEW (LPN)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:MATTEW
Last Name:ELLINGER
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15815 GORRILL RD
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-9787
Mailing Address - Country:US
Mailing Address - Phone:419-601-5457
Mailing Address - Fax:
Practice Address - Street 1:15815 GORRILL RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-9787
Practice Address - Country:US
Practice Address - Phone:419-601-5457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-22
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.142328-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse