Provider Demographics
NPI:1083342307
Name:ELLABOUDY, ANGIE (DNP, CPNP-PC)
Entity Type:Individual
Prefix:DR
First Name:ANGIE
Middle Name:
Last Name:ELLABOUDY
Suffix:
Gender:F
Credentials:DNP, CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 W WEEPING WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92865-1089
Mailing Address - Country:US
Mailing Address - Phone:714-679-9890
Mailing Address - Fax:
Practice Address - Street 1:26700 TOWNE CENTRE DR STE 150
Practice Address - Street 2:
Practice Address - City:FOOTHILL RANCH
Practice Address - State:CA
Practice Address - Zip Code:92610-2845
Practice Address - Country:US
Practice Address - Phone:949-837-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-13
Last Update Date:2022-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95020643363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP95020643OtherNP LICENSE/FURNISHING NUMBER