Basic Information
| Provider Information | |||||||||
| NPI: | 1932272127 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIN | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | KENETTE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NBC-HIS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ELLIN | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | KENETTE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NBC-HIS | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4155 YELLOWSTONE AVE | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832022345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082380020 | ||||||||
| FaxNumber: | 2082380021 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 N MERIDIAN | ||||||||
| Address2: | |||||||||
| City: | BLACKFOOT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087855551 | ||||||||
| FaxNumber: | 2087829580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 06/03/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | HA-182 | ID | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00441300 | 05 | ID | MEDICAID | 4414100 | 05 | ID | MEDICAID |