Provider Demographics
NPI:1518233030
Name:ELLSWORTH, AMY L (RD)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:L
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5281
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92615-5281
Mailing Address - Country:US
Mailing Address - Phone:714-376-4542
Mailing Address - Fax:
Practice Address - Street 1:524 12TH STREET
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-4034
Practice Address - Country:US
Practice Address - Phone:714-376-4542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1035075133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered