Healthcare Provider Details

I. General information

NPI: 1275495640
Provider Name (Legal Business Name): EMMA WELLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2025
Last Update Date: 12/14/2025
Certification Date: 12/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3314 S CICERO AVE UNIT B
CICERO IL
60804-4531
US

IV. Provider business mailing address

3314 S CICERO AVE
CICERO IL
60804-4531
US

V. Phone/Fax

Practice location:
  • Phone: 708-391-3030
  • Fax:
Mailing address:
  • Phone: 314-753-7557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.033718
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: