Healthcare Provider Details

I. General information

NPI: 1033769443
Provider Name (Legal Business Name): AMELL ELMOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2019
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date: 04/08/2026
Reactivation Date: 04/21/2026

III. Provider practice location address

12399 LEWIS ST STE 202
GARDEN GROVE CA
92840-4697
US

IV. Provider business mailing address

21600 OXNARD ST STE 1800
WOODLAND HILLS CA
91367-7807
US

V. Phone/Fax

Practice location:
  • Phone: 714-750-0575
  • Fax:
Mailing address:
  • Phone: 818-345-2345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95038333
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: