Healthcare Provider Details

I. General information

NPI: 1679022750
Provider Name (Legal Business Name): ELLIS NINONUEVO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2016
Last Update Date: 09/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 E CHAPMAN AVE
ORANGE CA
92866-2237
US

IV. Provider business mailing address

3942 ACACIA ST
IRVINE CA
92606-2628
US

V. Phone/Fax

Practice location:
  • Phone: 714-583-6431
  • Fax: 714-912-7432
Mailing address:
  • Phone: 949-861-0316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberRN 401698
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: