Provider Demographics
NPI:1780446278
Name:ELLIS, ALYSSA (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:ELLIS
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 1:1110 BAILEY RD
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3057
Mailing Address - Country:US
Mailing Address - Phone:815-762-1699
Mailing Address - Fax:
Practice Address - Street 1:1701 E WOODFIELD RD STE 401
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173-5126
Practice Address - Country:US
Practice Address - Phone:224-650-6275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-29
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209029497363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health