Provider Demographics
NPI:1720497902
Name:TROUTMAN, ELLISE
Entity Type:Individual
Prefix:
First Name:ELLISE
Middle Name:
Last Name:TROUTMAN
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 1:2310 EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31721-5225
Mailing Address - Country:US
Mailing Address - Phone:229-376-8641
Mailing Address - Fax:
Practice Address - Street 1:2310 EVERGREEN DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31721-5225
Practice Address - Country:US
Practice Address - Phone:229-376-8641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO0755131744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1744P3200XMedicaid