=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730948514
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELOM PSYCHIATRIC NURSE PRACTITIONERS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2024
-----------------------------------------------------
Last Update Date | 03/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1177 WOODBURY DR
-----------------------------------------------------
City | HARBOR CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90710-1242
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-729-4701
-----------------------------------------------------
Fax | 310-729-4701
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1177 WOODBURY DR
-----------------------------------------------------
City | HARBOR CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90710-1242
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-729-4701
-----------------------------------------------------
Fax | 310-729-4701
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANNE WINFREY
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 310-729-4701
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------