Provider Demographics
NPI:1114560695
Name:ELLSTROM, ALEXIS (PAC)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:ELLSTROM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 N GLENMORE ST
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-2700
Mailing Address - Country:US
Mailing Address - Phone:815-545-9592
Mailing Address - Fax:
Practice Address - Street 1:5701 W 79TH ST
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:IL
Practice Address - Zip Code:60459-1332
Practice Address - Country:US
Practice Address - Phone:708-499-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.007289363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant