Provider Demographics
NPI:1669983789
Name:STUART, ELIZABETH LAUREN (NP-C)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:LAUREN
Last Name:STUART
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:L
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:PO BOX 19636
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9636
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-788-5504
Practice Address - Street 1:751 N RUTLEDGE ST STE 1100
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4968
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-788-5504
Is Sole Proprietor?:No
Enumeration Date:2017-10-16
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.402814163W00000X
IL209.016146363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209-016146OtherSTATE LICENSE
IL209-016146OtherSTATE LICENSE