Provider Demographics
NPI:1922466739
Name:BALDWIN, ELISSA NICOLE (ATC)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:NICOLE
Last Name:BALDWIN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2043 COLLEGE WAY
Mailing Address - Street 2:PACIFIC UNIVERSITY ATHLETICS
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-1756
Mailing Address - Country:US
Mailing Address - Phone:503-352-2780
Mailing Address - Fax:
Practice Address - Street 1:2043 COLLEGE WAY
Practice Address - Street 2:PACIFIC UNIVERSITY ATHLETICS
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-1756
Practice Address - Country:US
Practice Address - Phone:503-352-2780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-08
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAT101492092255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer