Provider Demographics
NPI:1215539820
Name:LY, ELLEN (NP)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:LY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3452 E FOOTHILL BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-6006
Mailing Address - Country:US
Mailing Address - Phone:626-793-2885
Mailing Address - Fax:626-793-6262
Practice Address - Street 1:289 W HUNTINGTON DR STE 401
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-3493
Practice Address - Country:US
Practice Address - Phone:626-254-0074
Practice Address - Fax:626-254-0240
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA2020115166363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2020115166OtherAMERICAN NURSES CREDENTIALING CENTER
CA95016212OtherNURSE PRACTITIONER