Provider Demographics
NPI:1033543822
Name:MADLEM, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:MADLEM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 EASTLAND DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3534
Mailing Address - Country:US
Mailing Address - Phone:309-663-2100
Mailing Address - Fax:309-663-8322
Practice Address - Street 1:2222 E STATE ST STE 209
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-1572
Practice Address - Country:US
Practice Address - Phone:217-660-8850
Practice Address - Fax:815-977-5956
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.010900363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily