Provider Demographics
NPI:1811965973
Name:FELLINGHAM, SHARON DENISE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:SHARON
Middle Name:DENISE
Last Name:FELLINGHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:767 PARK AVE WEST SUITE #350
Mailing Address - Street 2:PARK AVE. ASSOCIATES IN INTERNAL MEDICINE
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035
Mailing Address - Country:US
Mailing Address - Phone:847-926-4445
Mailing Address - Fax:847-681-0994
Practice Address - Street 1:767 PARK AVE WEST SUITE #350
Practice Address - Street 2:PARK AVE. ASSOCIATES IN INTERNAL MEDICINE
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035
Practice Address - Country:US
Practice Address - Phone:773-549-7757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001834363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085001834OtherLICENSE
IL085001834OtherLICENSE