Provider Demographics
NPI:1689349391
Name:ICENHOUR, ELAINE RENE
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:RENE
Last Name:ICENHOUR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELAINE
Other - Middle Name:RENE
Other - Last Name:SHADY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, NP
Mailing Address - Street 1:5220 ROBERT J MATHEWS PKWY
Mailing Address - Street 2:
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-5705
Mailing Address - Country:US
Mailing Address - Phone:916-939-4960
Mailing Address - Fax:
Practice Address - Street 1:5220 ROBERT J MATHEWS PKWY
Practice Address - Street 2:
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-5705
Practice Address - Country:US
Practice Address - Phone:916-939-4960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9800363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner