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General NPI Number Information
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NPI Number | 1942800313
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Entity Type | Individual
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Provider Name | DR. AMANDA MARIE ELLISON
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Gender | Female
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Dates
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Enumeration Date | 10/27/2020
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Last Update Date | 10/27/2020
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Provider Practice Location Address
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Address Line | 21000 WESTERN AVE
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City | OLYMPIA FIELDS
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State | IL
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Zip | 60461-1935
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Country | US
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Telephone | 708-898-9114
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Fax |
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Provider Business Mailing Address
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Address Line | 9114 CARLISLE LN
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City | ORLAND PARK
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State | IL
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Zip | 60462-3377
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Country | US
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Telephone | 630-567-1146
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 051.299127
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License Number State | IL
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