Provider Demographics
NPI:1306918313
Name:ELLWANGER, CARA E (ATC)
Entity type:Individual
Prefix:
First Name:CARA
Middle Name:E
Last Name:ELLWANGER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 WOODLEY ST W APT 215
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-2746
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1381 JEFFERSON RD
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55057-3080
Practice Address - Country:US
Practice Address - Phone:507-646-8800
Practice Address - Fax:507-646-8801
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN19082255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer