Healthcare Provider Details

I. General information

NPI: 1083342307
Provider Name (Legal Business Name): ANGIE ELLABOUDY DNP, CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2022
Last Update Date: 08/13/2022
Certification Date: 08/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26700 TOWNE CENTRE DR STE 150
FOOTHILL RANCH CA
92610-2845
US

IV. Provider business mailing address

318 W WEEPING WILLOW AVE
ORANGE CA
92865-1089
US

V. Phone/Fax

Practice location:
  • Phone: 949-837-7337
  • Fax:
Mailing address:
  • Phone: 714-679-9890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number95020643
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: