Provider Demographics
NPI:1679022750
Name:NINONUEVO, ELLIS (NP)
Entity type:Individual
Prefix:
First Name:ELLIS
Middle Name:
Last Name:NINONUEVO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3942 ACACIA ST
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-2628
Mailing Address - Country:US
Mailing Address - Phone:949-861-0316
Mailing Address - Fax:
Practice Address - Street 1:1215 E CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-2237
Practice Address - Country:US
Practice Address - Phone:714-583-6431
Practice Address - Fax:714-912-7432
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-29
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN 401698363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health