Provider Demographics
NPI:1912194432
Name:ELY, MINDY S
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:S
Last Name:ELY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 DRAWBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-5247
Mailing Address - Country:US
Mailing Address - Phone:217-899-1193
Mailing Address - Fax:
Practice Address - Street 1:30 DRAWBRIDGE RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-5247
Practice Address - Country:US
Practice Address - Phone:217-899-1193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-28
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist