Healthcare Provider Details

I. General information

NPI: 1689390965
Provider Name (Legal Business Name): VICKI L ELLISON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2022
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 N LOCUST ST
TAMAROA IL
62888-4206
US

IV. Provider business mailing address

32 N LOCUST ST
TAMAROA IL
62888-4206
US

V. Phone/Fax

Practice location:
  • Phone: 618-357-0023
  • Fax:
Mailing address:
  • Phone: 618-357-0023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041480234
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: