Healthcare Provider Details

I. General information

NPI: 1639904006
Provider Name (Legal Business Name): EMILY ANNE MARTILLARO APRN,CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2024
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 ROOSEVELT RD STE A
GLEN ELLYN IL
60137-5618
US

IV. Provider business mailing address

285 ROOSEVELT RD STE A
GLEN ELLYN IL
60137-5618
US

V. Phone/Fax

Practice location:
  • Phone: 630-469-0045
  • Fax: 630-469-0645
Mailing address:
  • Phone: 630-469-0045
  • Fax: 630-469-0645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209030724
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.030724
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: