Provider Demographics
NPI:1336923754
Name:TEO, ELLEN I
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:I
Last Name:TEO
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 1:7700 YAKIMA VALLEY HWY
Mailing Address - Street 2:
Mailing Address - City:ZILLAH
Mailing Address - State:WA
Mailing Address - Zip Code:98953-9728
Mailing Address - Country:US
Mailing Address - Phone:509-930-8772
Mailing Address - Fax:
Practice Address - Street 1:511 S ELM ST
Practice Address - Street 2:
Practice Address - City:TOPPENISH
Practice Address - State:WA
Practice Address - Zip Code:98948-1651
Practice Address - Country:US
Practice Address - Phone:509-865-5121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-24
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACM61165991363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical