Provider Demographics
NPI:1992837843
Name:AGUSTIN, ELAINE GRACE (NP)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:GRACE
Last Name:AGUSTIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4485 CLEVELAND AVE
Mailing Address - Street 2:APT 5
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-3985
Mailing Address - Country:US
Mailing Address - Phone:626-484-7719
Mailing Address - Fax:
Practice Address - Street 1:401 E HIGHLAND AVE
Practice Address - Street 2:SUITE 551
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3803
Practice Address - Country:US
Practice Address - Phone:909-882-9150
Practice Address - Fax:909-883-8972
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CANP 13423363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN 549365OtherREGISTERED NURSE
CANP 13423OtherNURSE PRACTITIONER