Provider Demographics
NPI:1083255343
Name:ELLINGWOOD, LISA ANNETTE (APRN, PMHNP-BC)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANNETTE
Last Name:ELLINGWOOD
Suffix:
Gender:F
Credentials:APRN, PMHNP-BC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANNETTE
Other - Last Name:ELLINGWOOD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:1802 S. MATTIS AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821
Mailing Address - Country:US
Mailing Address - Phone:217-365-2855
Mailing Address - Fax:217-365-2856
Practice Address - Street 1:1802 S MATTIS AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-5923
Practice Address - Country:US
Practice Address - Phone:217-365-2855
Practice Address - Fax:217-365-2856
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-07
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.385774163W00000X
IL209.020407363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse