Basic Information
| Provider Information | |||||||||
| NPI: | 1710955067 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SACKETT | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40767 | ||||||||
| Address2: | CREDENTIALING DEPARTMENT | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322030767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043763707 | ||||||||
| FaxNumber: | 9043915807 | ||||||||
| Practice Location | |||||||||
| Address1: | 6142 COLLINS RD | ||||||||
| Address2: | CREDENTIALING DEPARTMENT | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322445806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047783200 | ||||||||
| FaxNumber: | 9047789835 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2006 | ||||||||
| LastUpdateDate: | 02/02/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME54002 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.