Healthcare Provider Details

I. General information

NPI: 1346418985
Provider Name (Legal Business Name): MELONY D ELLIS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2008
Last Update Date: 02/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N 1ST ST ANESTHESIA DEPARTMENT
SPRINGFIELD IL
62781-0002
US

IV. Provider business mailing address

701 N 1ST ST ANESTHESIA DEPARTMENT
SPRINGFIELD IL
62781-0001
US

V. Phone/Fax

Practice location:
  • Phone: 217-788-7354
  • Fax: 217-788-7021
Mailing address:
  • Phone: 217-788-7354
  • Fax: 217-788-7021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: