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General NPI Number Information
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NPI Number | 1952705006
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Entity Type | Individual
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Provider Name | ELLAWEASE EARLS
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Gender | Female
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Dates
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Enumeration Date | 10/17/2014
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Last Update Date | 10/17/2014
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Provider Practice Location Address
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Address Line | 8801 S CONSTANCE AVE
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City | CHICAGO
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State | IL
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Zip | 60617-2955
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Country | US
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Telephone | 773-206-2468
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Fax | 773-382-0333
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Provider Business Mailing Address
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Address Line | 8801 S CONSTANCE AVE
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City | CHICAGO
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State | IL
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Zip | 60617-2955
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Country | US
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Telephone | 773-206-2468
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Fax | 773-382-0333
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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 | 171W00000X
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Taxonomy Name | Contractor
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License Number |
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License Number State |
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