Provider Demographics
NPI:1114245958
Name:FENNELL, ELLY JO (RN, CNP)
Entity Type:Individual
Prefix:MRS
First Name:ELLY
Middle Name:JO
Last Name:FENNELL
Suffix:
Gender:F
Credentials:RN, CNP
Other - Prefix:
Other - First Name:ELLY
Other - Middle Name:J
Other - Last Name:WEAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3900 ST FRANCIS WAY STE 205
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-4939
Mailing Address - Country:US
Mailing Address - Phone:765-428-2500
Mailing Address - Fax:765-428-2505
Practice Address - Street 1:720 ESKENAZI AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5187
Practice Address - Country:US
Practice Address - Phone:317-880-7666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-04
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.008173363L00000X, 363LA2200X
IL370911138363LA2200X
IN71009460A364S00000X
IL041-280081163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041-280081OtherRN LICENSE
IL036102163Medicaid
IL209.008173OtherCNP LICENSE
IL209.008173OtherCNP LICENSE