Basic Information
| Provider Information | |||||||||
| NPI: | 1972069631 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELIT | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | AGACNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ELIT | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LOE | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2211 PACIFIC BEACH DR | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921095626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076961779 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1751 E HARRY AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778967350 | ||||||||
| FaxNumber: | 8003407804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2019 | ||||||||
| LastUpdateDate: | 02/18/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | NP95010996 | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | NPF95010996 | 05 | CA | MEDICAID |