Provider Demographics
NPI:1972069631
Name:ELIT, AMY MARIE (AGACNP)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:MARIE
Last Name:ELIT
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:MRS
Other - First Name:AMY
Other - Middle Name:MARIE
Other - Last Name:ELIT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LOE
Mailing Address - Street 1:2211 PACIFIC BEACH DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-5626
Mailing Address - Country:US
Mailing Address - Phone:507-696-1779
Mailing Address - Fax:
Practice Address - Street 1:1751 E HARRY AVE
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705
Practice Address - Country:US
Practice Address - Phone:877-896-7350
Practice Address - Fax:800-340-7804
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95010996363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANPF95010996Medicaid