Healthcare Provider Details

I. General information

NPI: 1922331578
Provider Name (Legal Business Name): DONNA ELLIS APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE
CHICAGO IL
60637-1447
US

IV. Provider business mailing address

150 HARVESTER DR STE 300
BURR RIDGE IL
60527-5965
US

V. Phone/Fax

Practice location:
  • Phone: 844-755-8267
  • Fax:
Mailing address:
  • Phone: 844-755-8267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number209004779
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number209004779
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: