Provider Demographics
NPI:1962732370
Name:ELLENBECKER, AMY LOU (DC)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:LOU
Last Name:ELLENBECKER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:AMY
Other - Middle Name:LOU
Other - Last Name:PETRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:1050 31ST AVE SW STE C
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-2005
Mailing Address - Country:US
Mailing Address - Phone:701-839-2010
Mailing Address - Fax:701-838-3497
Practice Address - Street 1:1050 31ST AVE SW STE C
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-2005
Practice Address - Country:US
Practice Address - Phone:701-839-2010
Practice Address - Fax:701-838-3497
Is Sole Proprietor?:No
Enumeration Date:2010-01-06
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND854111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor