Provider Demographics
NPI:1386284495
Name:ROLETT, ELLYNN JOANN (LAT, ATC)
Entity type:Individual
Prefix:
First Name:ELLYNN
Middle Name:JOANN
Last Name:ROLETT
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 ENERGY CENTER BLVD APT 3414
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35473-2736
Mailing Address - Country:US
Mailing Address - Phone:309-264-5787
Mailing Address - Fax:
Practice Address - Street 1:219 INDUSTRIAL PARK ST
Practice Address - Street 2:
Practice Address - City:GORDO
Practice Address - State:AL
Practice Address - Zip Code:35466-2068
Practice Address - Country:US
Practice Address - Phone:205-364-1003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL21632255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer