Provider Demographics
NPI:1902188550
Name:ELLINGBOE, SANDRA JO
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:JO
Last Name:ELLINGBOE
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 1:1411 E COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258-2086
Mailing Address - Country:US
Mailing Address - Phone:507-532-2264
Mailing Address - Fax:507-532-6920
Practice Address - Street 1:1411 E COLLEGE DR
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-2086
Practice Address - Country:US
Practice Address - Phone:507-532-2264
Practice Address - Fax:507-532-6920
Is Sole Proprietor?:No
Enumeration Date:2011-09-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL56707-7164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse