Provider Demographics
NPI:1104873934
Name:BALTZ, ELLYN LEIGH (RD, LD/N)
Entity type:Individual
Prefix:
First Name:ELLYN
Middle Name:LEIGH
Last Name:BALTZ
Suffix:
Gender:F
Credentials:RD, LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 54TH ST S
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33707-5511
Mailing Address - Country:US
Mailing Address - Phone:727-322-0470
Mailing Address - Fax:
Practice Address - Street 1:2601 54TH ST S
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:FL
Practice Address - Zip Code:33707-5511
Practice Address - Country:US
Practice Address - Phone:727-322-0470
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND4122133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered