Provider Demographics
NPI:1245704261
Name:ELLERIN, AMBER
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:ELLERIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38135 MARKET SQ
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-7505
Mailing Address - Country:US
Mailing Address - Phone:352-567-0188
Mailing Address - Fax:813-355-5101
Practice Address - Street 1:13417 US HIGHWAY 301 STE D
Practice Address - Street 2:
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33525-5446
Practice Address - Country:US
Practice Address - Phone:352-567-8640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-12
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLPA9114743363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program