Healthcare Provider Details

I. General information

NPI: 1407514177
Provider Name (Legal Business Name): ELLENITA GALLEGOS GUICO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2021
Last Update Date: 04/10/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7765 LEEDS ST
DOWNEY CA
90242-3489
US

IV. Provider business mailing address

7765 LEEDS ST
DOWNEY CA
90242-3489
US

V. Phone/Fax

Practice location:
  • Phone: 562-674-1714
  • Fax:
Mailing address:
  • Phone: 562-674-1714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number697816
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP95019885
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: