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1114245958 NPI number — ELLY JO FENNELL RN, CNP

NPI Number: 1114245958
Health Care Provider/Practitioner: ELLY JO FENNELL RN, CNP

Information about “1114245958” NPI (ELLY JO FENNELL RN, CNP) exists in 1114245958 in HTML format HTML  |  1114245958 in plain Text format TXT  |  1114245958 in PDF (Portable Document Format) PDF  |  1114245958 in an XML format XML  formats.

NPI Number : 1114245958 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1114245958",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "FENNELL",
    "FirstName": "ELLY",
    "MiddleName": "JO",
    "NamePrefix": "MRS.",
    "NameSuffix": null,
    "Credential": "RN, CNP",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": "WEAR",
    "OtherFirstName": "ELLY",
    "OtherMiddleName": "J",
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": "1",
    "FirstLineMailingAddress": "PO BOX 637764",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "CINCINNATI",
    "MailingAddressStateName": "OH",
    "MailingAddressPostalCode": "45263-7764",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "317-880-3939",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "720 ESKENAZI AVE",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "INDIANAPOLIS",
    "PracticeLocationAddressStateName": "IN",
    "PracticeLocationAddressPostalCode": "46202-5187",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "317-880-7666",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "05/04/2010",
    "LastUpdateDate": "09/16/2025",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "363LA2200X",
          "TaxonomyName": "Adult Health Nurse Practitioner",
          "LicenseNumber": "209.008173",
          "LicenseNumberStateCode": "IL",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "364S00000X",
          "TaxonomyName": "Clinical Nurse Specialist",
          "LicenseNumber": "71009460A",
          "LicenseNumberStateCode": "IN",
          "PrimaryTaxonomySwitch": "Y"
        },
        {
          "TaxonomyCode": "163W00000X",
          "TaxonomyName": "Registered Nurse",
          "LicenseNumber": "041-280081",
          "LicenseNumberStateCode": "IL",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "363LA2200X",
          "TaxonomyName": "Adult Health Nurse Practitioner",
          "LicenseNumber": "370911138",
          "LicenseNumberStateCode": "IL",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "363L00000X",
          "TaxonomyName": "Nurse Practitioner",
          "LicenseNumber": "209.008173",
          "LicenseNumberStateCode": "IL",
          "PrimaryTaxonomySwitch": "N"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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