Provider Demographics
NPI:1184275448
Name:ELIZALDE, MARNELLA (NP-C)
Entity type:Individual
Prefix:
First Name:MARNELLA
Middle Name:
Last Name:ELIZALDE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 FAIRFIELD WAY STE 205
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-1500
Mailing Address - Country:US
Mailing Address - Phone:630-915-2037
Mailing Address - Fax:
Practice Address - Street 1:109 FAIRFIELD WAY STE 207
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-1500
Practice Address - Country:US
Practice Address - Phone:630-915-2037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-26
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209019916363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily