Provider Demographics
NPI:1073677753
Name:DENNISS, ELIZABETH K (NP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:K
Last Name:DENNISS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 ARABIAN TRL
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-1567
Mailing Address - Country:US
Mailing Address - Phone:217-546-8112
Mailing Address - Fax:
Practice Address - Street 1:800 E CARPENTER ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62769-0001
Practice Address - Country:US
Practice Address - Phone:217-544-6464
Practice Address - Fax:217-544-3989
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
S98155Medicare UPIN
IL207775Medicare PIN