Provider Demographics
NPI:1780100776
Name:ELLENBERG, BEVIN LYLE (CRNP)
Entity type:Individual
Prefix:
First Name:BEVIN
Middle Name:LYLE
Last Name:ELLENBERG
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12366
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35202-2366
Mailing Address - Country:US
Mailing Address - Phone:205-780-7101
Mailing Address - Fax:205-206-8338
Practice Address - Street 1:832 PRINCETON AVE SW
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35211-1320
Practice Address - Country:US
Practice Address - Phone:205-206-8450
Practice Address - Fax:205-206-8364
Is Sole Proprietor?:No
Enumeration Date:2017-08-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-140234363LA2200X, 363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology