Provider Demographics
NPI:1013498187
Name:ELSTON, RENEE NICOLE (PTA)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:NICOLE
Last Name:ELSTON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8001 BROWNSTONE RD APT 124
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79765-8717
Mailing Address - Country:US
Mailing Address - Phone:318-286-8326
Mailing Address - Fax:
Practice Address - Street 1:5001 OFFICE PARK APT 124
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-4843
Practice Address - Country:US
Practice Address - Phone:318-286-8326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2117756208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation