Healthcare Provider Details

I. General information

NPI: 1598225344
Provider Name (Legal Business Name): ELISSA TOWNSEND APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 03/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1029 N 8TH STREET
VANDALLA IL
62471-1238
US

IV. Provider business mailing address

1029 N 8TH STREET
VANDALLA IL
62471-1238
US

V. Phone/Fax

Practice location:
  • Phone: 618-283-4469
  • Fax: 618-283-4797
Mailing address:
  • Phone: 618-283-4469
  • Fax: 618-283-4797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209018984
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: