1972069631 NPI number — MRS. AMY MARIE ELIT AGACNP

Table of content: MRS. AMY MARIE ELIT AGACNP (NPI 1972069631)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972069631 NPI number — MRS. AMY MARIE ELIT AGACNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELIT
Provider First Name:
AMY
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
AGACNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ELIT
Provider Other First Name:
AMY
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LOE
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1972069631
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2211 PACIFIC BEACH DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92109-5626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-696-1779
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1751 E HARRY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA ANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-896-7350
Provider Business Practice Location Address Fax Number:
800-340-7804
Provider Enumeration Date:
02/18/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  NP95010996 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NPF95010996 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com