Basic Information
| Provider Information | |||||||||
| NPI: | 1063558856 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | ELAINE | ||||||||
| MiddleName: | DE JESUS | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | HAD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DE JESUS | ||||||||
| OtherFirstName: | ELAINE | ||||||||
| OtherMiddleName: | MOLINA | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12927 SLEEPY WIND ST | ||||||||
| Address2: | |||||||||
| City: | MOORPARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930212935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194260841 | ||||||||
| FaxNumber: | 6194269197 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 3RD AVE | ||||||||
| Address2: | STE C11 | ||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919103953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194260841 | ||||||||
| FaxNumber: | 6194269197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 04/26/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | HA 7100 | CA | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
No ID Information.