Provider Demographics
NPI:1659045524
Name:ELLERBROCK, HEATHER RENEA (LPN/MDS COORDINATOR)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:RENEA
Last Name:ELLERBROCK
Suffix:
Gender:F
Credentials:LPN/MDS COORDINATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 OTTAWA ST
Mailing Address - Street 2:
Mailing Address - City:KALIDA
Mailing Address - State:OH
Mailing Address - Zip Code:45853-2096
Mailing Address - Country:US
Mailing Address - Phone:419-532-2961
Mailing Address - Fax:419-532-2962
Practice Address - Street 1:755 OTTAWA ST
Practice Address - Street 2:
Practice Address - City:KALIDA
Practice Address - State:OH
Practice Address - Zip Code:45853-2096
Practice Address - Country:US
Practice Address - Phone:419-532-2961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH154693164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse