Provider Demographics
NPI:1316571151
Name:DEKOLD, ELLEN (APN)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:
Last Name:DEKOLD
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11750 WINDING TRAILS DR
Mailing Address - Street 2:
Mailing Address - City:WILLOW SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60480-1191
Mailing Address - Country:US
Mailing Address - Phone:630-432-9830
Mailing Address - Fax:
Practice Address - Street 1:1S072 LUTHER AVE
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-4164
Practice Address - Country:US
Practice Address - Phone:630-247-8877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-02
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.019486363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner