Healthcare Provider Details

I. General information

NPI: 1124834593
Provider Name (Legal Business Name): ELLEN REGINA DUBACH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2024
Last Update Date: 12/10/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3751 KATELLA AVE
LOS ALAMITOS CA
90720-3113
US

IV. Provider business mailing address

3751 KATELLA AVE
LOS ALAMITOS CA
90720-3113
US

V. Phone/Fax

Practice location:
  • Phone: 714-342-7337
  • Fax:
Mailing address:
  • Phone: 714-342-7337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN951196705
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code364SC0200X
TaxonomyCritical Care Medicine Clinical Nurse Specialist
License NumberRN951196705
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: