Provider Demographics
NPI:1770956526
Name:ELLISON, MARIE-ANGE THI HUYEN TRAN (LAC)
Entity type:Individual
Prefix:
First Name:MARIE-ANGE
Middle Name:THI HUYEN TRAN
Last Name:ELLISON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 CENTER AVE
Mailing Address - Street 2:SUITE 180
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-3063
Mailing Address - Country:US
Mailing Address - Phone:714-897-7546
Mailing Address - Fax:714-897-7549
Practice Address - Street 1:7777 CENTER AVE
Practice Address - Street 2:SUITE 180
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-3063
Practice Address - Country:US
Practice Address - Phone:714-897-7546
Practice Address - Fax:714-897-7549
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC16801171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC 16801OtherACUPUNCTURE BOARD