Provider Demographics
NPI:1902817646
Name:DE JONG, ELLEN ELIZABETH (PT)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:ELIZABETH
Last Name:DE JONG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:ELLEN
Other - Middle Name:ELIZABETH
Other - Last Name:MAGUIRE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:6365 N CROATAN HWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:KITTY HAWK
Mailing Address - State:NC
Mailing Address - Zip Code:27949-3800
Mailing Address - Country:US
Mailing Address - Phone:252-261-6489
Mailing Address - Fax:
Practice Address - Street 1:6365 N CROATAN HWY
Practice Address - Street 2:SUITE C
Practice Address - City:KITTY HAWK
Practice Address - State:NC
Practice Address - Zip Code:27949-3800
Practice Address - Country:US
Practice Address - Phone:252-261-6489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5494225100000X
VA2305003181225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC53756OtherBCBS
2506120Medicare PIN