Healthcare Provider Details

I. General information

NPI: 1689006819
Provider Name (Legal Business Name): HEATHER H ELLEDGE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2013
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1154 E GRAND AVE
ARROYO GRANDE CA
93420-2583
US

IV. Provider business mailing address

1154 E GRAND AVE
ARROYO GRANDE CA
93420-2583
US

V. Phone/Fax

Practice location:
  • Phone: 805-395-3277
  • Fax:
Mailing address:
  • Phone: 248-225-4408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA23119
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPA23119
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: