Provider Demographics
NPI:1053733543
Name:AMMAR, SALLY
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:AMMAR
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 1:468 N CAMDEN DR # 200
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4507
Mailing Address - Country:US
Mailing Address - Phone:310-292-9292
Mailing Address - Fax:
Practice Address - Street 1:714 AVALON BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744
Practice Address - Country:US
Practice Address - Phone:310-522-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-17
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51345363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant