Provider Demographics
NPI:1023134699
Name:FERRELL, ELIZABETH ANNE (RDH CPDH BS)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:ANNE
Last Name:FERRELL
Suffix:
Gender:F
Credentials:RDH CPDH BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1953
Mailing Address - Street 2:
Mailing Address - City:TIJERAS
Mailing Address - State:NM
Mailing Address - Zip Code:87059
Mailing Address - Country:US
Mailing Address - Phone:505-379-2131
Mailing Address - Fax:
Practice Address - Street 1:400 SAN FELIPE NW
Practice Address - Street 2:SUITE F
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87104
Practice Address - Country:US
Practice Address - Phone:505-379-2131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH1453124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM72923733Medicaid