Provider Demographics
NPI:1003352196
Name:ELLIS, DEBORA (APRN)
Entity Type:Individual
Prefix:DR
First Name:DEBORA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2081 CALISTOGA DR STE 2S
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-4833
Mailing Address - Country:US
Mailing Address - Phone:815-418-6070
Mailing Address - Fax:708-923-5018
Practice Address - Street 1:201 E OGDEN AVE STE 118
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3776
Practice Address - Country:US
Practice Address - Phone:630-270-7717
Practice Address - Fax:779-803-3119
Is Sole Proprietor?:No
Enumeration Date:2017-01-12
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277.000609363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDF400362016OtherMEDICARE PTAN