Healthcare Provider Details

I. General information

NPI: 1083255343
Provider Name (Legal Business Name): LISA ANNETTE ELLINGWOOD APRN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LISA ANNETTE ELLINGWOOD RN

II. Dates (important events)

Enumeration Date: 10/07/2019
Last Update Date: 04/22/2024
Certification Date: 06/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 S MATTIS AVE
CHAMPAIGN IL
61821-5923
US

IV. Provider business mailing address

1802 S. MATTIS AVE
CHAMPAIGN IL
61821
US

V. Phone/Fax

Practice location:
  • Phone: 217-365-2855
  • Fax: 217-365-2856
Mailing address:
  • Phone: 217-365-2855
  • Fax: 217-365-2856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.020407
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.385774
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: