Provider Demographics
NPI:1689819435
Name:ELLIS, CHERYL (APN)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:CHERYL
Other - Middle Name:
Other - Last Name:BEISNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:109 CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-1923
Mailing Address - Country:US
Mailing Address - Phone:618-985-8221
Mailing Address - Fax:
Practice Address - Street 1:7 SOUTH HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-3333
Practice Address - Country:US
Practice Address - Phone:618-687-3418
Practice Address - Fax:618-687-1859
Is Sole Proprietor?:No
Enumeration Date:2008-12-09
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209007184363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL161401OtherHEALTH ALLIANCE
IL370966854005Medicaid
IL370966854002Medicaid
ILCF3444OtherMEDICARE RR
IL370966854005Medicaid
IL640701Medicare Oscar/Certification
IL161401OtherHEALTH ALLIANCE