Healthcare Provider Details

I. General information

NPI: 1205346053
Provider Name (Legal Business Name): ALEXIS GELLAR AGPCNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2017
Last Update Date: 02/16/2023
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3880 SALEM LAKE DR STE F
LONG GROVE IL
60047-5292
US

IV. Provider business mailing address

3880 SALEM LAKE DR STE F
LONG GROVE IL
60047-5292
US

V. Phone/Fax

Practice location:
  • Phone: 847-719-2220
  • Fax: 847-719-2265
Mailing address:
  • Phone: 847-719-2220
  • Fax: 847-719-2265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209.016584
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: