Healthcare Provider Details

I. General information

NPI: 1518110725
Provider Name (Legal Business Name): MRS. ELEANOR M. RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2008
Last Update Date: 12/31/2021
Certification Date: 12/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 DIANE LN
ELK GROVE VILLAGE IL
60007-3056
US

IV. Provider business mailing address

1229 DIANE LN
ELK GROVE VILLAGE IL
60007-3056
US

V. Phone/Fax

Practice location:
  • Phone: 847-352-9425
  • Fax: 847-985-0226
Mailing address:
  • Phone: 847-352-9425
  • Fax: 847-985-0226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number209.005019
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number041.170533
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: