Provider Demographics
NPI:1922313238
Name:ELLIS, STEPHANIE M (PA)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:M
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4909 N GLEN PARK PLACE RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4676
Mailing Address - Country:US
Mailing Address - Phone:309-674-7546
Mailing Address - Fax:309-282-0500
Practice Address - Street 1:4909 N GLEN PARK PLACE RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4676
Practice Address - Country:US
Practice Address - Phone:309-674-7546
Practice Address - Fax:309-282-0500
Is Sole Proprietor?:No
Enumeration Date:2010-08-11
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant