Healthcare Provider Details

I. General information

NPI: 1053532630
Provider Name (Legal Business Name): ELLYN JANINE ANNORENO PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 SOUTH RIVERSIDE PLAZA SUITE 830
CHICAGO IL
60606
US

IV. Provider business mailing address

217 N. OAK AVE.
BARTLETT IL
60103-4063
US

V. Phone/Fax

Practice location:
  • Phone: 312-416-3804
  • Fax:
Mailing address:
  • Phone: 630-372-7616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: