Healthcare Provider Details

I. General information

NPI: 1184101883
Provider Name (Legal Business Name): AMBER ELMORE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2018
Last Update Date: 07/29/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4672 MAVERICK LN STE 1
LAKESIDE AZ
85929-5459
US

IV. Provider business mailing address

1295 PASSAGE DR
SHOW LOW AZ
85901-6905
US

V. Phone/Fax

Practice location:
  • Phone: 928-368-7346
  • Fax: 928-495-5514
Mailing address:
  • Phone: 928-368-7346
  • Fax: 928-495-5514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LA0401X
TaxonomyAddiction Medicine (Anesthesiology) Physician
License Number71525
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number71525
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: