Provider Demographics
NPI:1275385361
Name:BALLARD, ELISE D (NP)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:D
Last Name:BALLARD
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 1:120 W 22ND ST
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1557
Mailing Address - Country:US
Mailing Address - Phone:630-573-5000
Mailing Address - Fax:630-491-5472
Practice Address - Street 1:10120 CALUMET AVE STE 103
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-4076
Practice Address - Country:US
Practice Address - Phone:219-836-2936
Practice Address - Fax:219-836-2949
Is Sole Proprietor?:No
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN209028641363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily