Provider Demographics
NPI:1508245028
Name:ELLISON, CARLY (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:ELLISON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 OLD JACKSONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-7437
Mailing Address - Country:US
Mailing Address - Phone:217-698-9722
Mailing Address - Fax:217-391-0392
Practice Address - Street 1:7900 E UNION AVE STE 1100
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80237-2746
Practice Address - Country:US
Practice Address - Phone:303-414-1164
Practice Address - Fax:813-906-7789
Is Sole Proprietor?:No
Enumeration Date:2015-05-29
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012884363LF0000X, 363LP2300X
COC-APN.0003842-C-NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care