Provider Demographics
NPI:1841603917
Name:LAUDERDALE, ELISE (ANP)
Entity Type:Individual
Prefix:MRS
First Name:ELISE
Middle Name:
Last Name:LAUDERDALE
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:MISS
Other - First Name:ELISE
Other - Middle Name:
Other - Last Name:BOWMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:5841 S MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-1447
Mailing Address - Country:US
Mailing Address - Phone:773-702-1000
Mailing Address - Fax:773-926-0852
Practice Address - Street 1:5841 S MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1447
Practice Address - Country:US
Practice Address - Phone:773-702-1000
Practice Address - Fax:773-926-0852
Is Sole Proprietor?:No
Enumeration Date:2014-06-06
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010248363LA2200X
PASP013050363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health