Healthcare Provider Details

I. General information

NPI: 1043634413
Provider Name (Legal Business Name): AUBRIE KLISA AMELANG M.ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2014
Last Update Date: 02/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 E VILLA ST APT 29
PASADENA CA
91106-1045
US

IV. Provider business mailing address

1001 E VILLA ST APT 29
PASADENA CA
91106-1045
US

V. Phone/Fax

Practice location:
  • Phone: 208-219-2211
  • Fax:
Mailing address:
  • Phone: 208-219-2211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: