MEDICARE: KHALIAH YVONNE ELLISTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	096.004400	IL

General Provider Information

NPI Number	:	1942740881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KHALIAH YVONNE ELLISTON

Provider Business Mailing Address
First Line	:	6111 S DREXEL AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60637-2627
Country	:	US
Telephone Number	:	773-297-1023
Fax Number	:

Provider Business Practice Location Address
First Line	:	1629 CHICAGO AVE
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60201-4504
Country	:	US
Telephone Number	:	773-297-1023
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/25/2017
Last Update Date	:	02/25/2017

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