Provider Demographics
NPI:1821071507
Name:ELLERBROEK, NANCY A
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:A
Last Name:ELLERBROEK
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:PO BOX 513969
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-3969
Mailing Address - Country:US
Mailing Address - Phone:310-335-4065
Mailing Address - Fax:310-335-4098
Practice Address - Street 1:25751 MCBEAN PKWY
Practice Address - Street 2:STE. 110
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-3701
Practice Address - Country:US
Practice Address - Phone:661-259-2990
Practice Address - Fax:661-259-1031
Is Sole Proprietor?:No
Enumeration Date:2005-11-27
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53683174400000X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO19874545Medicaid
CA00G536830Medicaid
CO19874545Medicaid
CA00G536830Medicaid
CABQ961Medicare PIN