Provider Demographics
NPI:1053858779
Name:ENTSUAH, AMETHYST
Entity Type:Individual
Prefix:
First Name:AMETHYST
Middle Name:
Last Name:ENTSUAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 E KATELLA AVE
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-6614
Mailing Address - Country:US
Mailing Address - Phone:714-633-6373
Mailing Address - Fax:
Practice Address - Street 1:15403 PARK AVE E
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2482
Practice Address - Country:US
Practice Address - Phone:714-633-6373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-20
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95052687163W00000X
CA95024030363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse