Healthcare Provider Details

I. General information

NPI: 1114245958
Provider Name (Legal Business Name): ELLY JO FENNELL RN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELLY J WEAR

II. Dates (important events)

Enumeration Date: 05/04/2010
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 ESKENAZI AVE
INDIANAPOLIS IN
46202-5187
US

IV. Provider business mailing address

PO BOX 637764
CINCINNATI OH
45263-7764
US

V. Phone/Fax

Practice location:
  • Phone: 317-880-7666
  • Fax:
Mailing address:
  • Phone: 317-880-3939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209.008173
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number71009460A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041-280081
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number370911138
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.008173
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: