Provider Demographics
NPI:1932272127
Name:ELLIN, ELIZABETH KENETTE (NBC-HIS)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:KENETTE
Last Name:ELLIN
Suffix:
Gender:F
Credentials:NBC-HIS
Other - Prefix:MRS
Other - First Name:ELIZABETH
Other - Middle Name:KENETTE
Other - Last Name:ELLIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NBC-HIS
Mailing Address - Street 1:4155 YELLOWSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2345
Mailing Address - Country:US
Mailing Address - Phone:208-238-0020
Mailing Address - Fax:208-238-0021
Practice Address - Street 1:720 N MERIDIAN
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221
Practice Address - Country:US
Practice Address - Phone:208-785-5551
Practice Address - Fax:208-782-9580
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDHA-182237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID00441300Medicaid
ID4414100Medicaid