Provider Demographics
NPI:1851572267
Name:LOUDERMILK, ELIZABETH DIANE (CRNA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:DIANE
Last Name:LOUDERMILK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:DIANE
Other - Last Name:OLSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:2202 HARLEM RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-2754
Mailing Address - Country:US
Mailing Address - Phone:815-877-4848
Mailing Address - Fax:815-636-6125
Practice Address - Street 1:2202 HARLEM RD
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-2754
Practice Address - Country:US
Practice Address - Phone:815-877-4848
Practice Address - Fax:815-636-6125
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.012616367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8K2947Medicare PIN