Provider Demographics
NPI:1811687312
Name:ALSUP, ELISSA (RN)
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:
Last Name:ALSUP
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 W MONTROSE AVE # 901
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-2140
Mailing Address - Country:US
Mailing Address - Phone:773-340-0822
Mailing Address - Fax:
Practice Address - Street 1:320 E 21ST ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-3190
Practice Address - Country:US
Practice Address - Phone:773-340-0822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041379530163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse