Provider Demographics
NPI:1568255396
Name:DETWILER, ELLEN (NP)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:DETWILER
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 1:2106 W HUNTINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-1625
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2106 W HUNTINGTON AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-1625
Practice Address - Country:US
Practice Address - Phone:714-612-6578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-24
Last Update Date:2025-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95032024363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner