Healthcare Provider Details

I. General information

NPI: 1528079803
Provider Name (Legal Business Name): LARA M. ELLISON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 03/26/2021
Certification Date: 03/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2007 95TH STREET SUITE 105
NAPERVILLE IL
60563-7802
US

IV. Provider business mailing address

2007 95TH ST STE 105
NAPERVILLE IL
60563-7802
US

V. Phone/Fax

Practice location:
  • Phone: 630-646-6920
  • Fax: 630-646-6925
Mailing address:
  • Phone: 630-646-6920
  • Fax: 630-646-6925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036114549
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: