Provider Demographics
NPI:1396004776
Name:FERRELL, ILLISE (FNP-NP)
Entity Type:Individual
Prefix:
First Name:ILLISE
Middle Name:
Last Name:FERRELL
Suffix:
Gender:F
Credentials:FNP-NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29640 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:WICKLIFFE
Mailing Address - State:OH
Mailing Address - Zip Code:44092-1829
Mailing Address - Country:US
Mailing Address - Phone:440-463-9596
Mailing Address - Fax:
Practice Address - Street 1:29640 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:WICKLIFFE
Practice Address - State:OH
Practice Address - Zip Code:44092
Practice Address - Country:US
Practice Address - Phone:440-463-9596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-07
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.371331163W00000X
OHAPRN.CNP.0022454363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0268768Medicaid