Healthcare Provider Details

I. General information

NPI: 1245704261
Provider Name (Legal Business Name): AMBER ELLERIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2019
Last Update Date: 10/14/2021
Certification Date: 10/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13417 US HIGHWAY 301 STE D
DADE CITY FL
33525-5446
US

IV. Provider business mailing address

38135 MARKET SQ
ZEPHYRHILLS FL
33542-7505
US

V. Phone/Fax

Practice location:
  • Phone: 352-567-8640
  • Fax:
Mailing address:
  • Phone: 352-567-0188
  • Fax: 813-355-5101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9114743
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: