Healthcare Provider Details

I. General information

NPI: 1992171698
Provider Name (Legal Business Name): COLLEEN ELLIOTT-MCCANDLESS APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: COLLEEN ELLIOTT APN

II. Dates (important events)

Enumeration Date: 08/17/2015
Last Update Date: 05/09/2024
Certification Date: 05/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 FRANKLIN AVE STE 380
NORMAL IL
61761-3558
US

IV. Provider business mailing address

611 W PARK ST FAPC
URBANA IL
61821-2500
US

V. Phone/Fax

Practice location:
  • Phone: 309-268-5130
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209013060
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: