Healthcare Provider Details

I. General information

NPI: 1649728874
Provider Name (Legal Business Name): EMILY COELLO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2016
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12255 S 80TH AVE STE 204
PALOS HEIGHTS IL
60463-1284
US

IV. Provider business mailing address

12255 S 80TH AVE STE 204
PALOS HEIGHTS IL
60463-1284
US

V. Phone/Fax

Practice location:
  • Phone: 708-923-4400
  • Fax: 708-923-4421
Mailing address:
  • Phone: 708-923-4400
  • Fax: 708-923-4421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085005972
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: