Provider Demographics
NPI:1639325129
Name:ELLIS-PELLETIER, AMANDA DAWN (DO)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:DAWN
Last Name:ELLIS-PELLETIER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1425
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:
Practice Address - Street 1:1675 W DEMPSTER ST
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1110
Practice Address - Country:US
Practice Address - Phone:847-723-5313
Practice Address - Fax:847-723-2325
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-15
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1208802080P0203X
IL036120880208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics