Healthcare Provider Details

I. General information

NPI: 1710005558
Provider Name (Legal Business Name): MS. SUE ELLEN ANNIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 03/26/2021
Certification Date: 03/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17707 STUDEBAKER RD STE 208
CERRITOS CA
90703-2640
US

IV. Provider business mailing address

17707 STUDEBAKER RD STE 208
CERRITOS CA
90703-2640
US

V. Phone/Fax

Practice location:
  • Phone: 562-402-0677
  • Fax:
Mailing address:
  • Phone: 562-402-0677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: