Provider Demographics
NPI:1821010281
Name:MOON, ELLEN (NP)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:J
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:150 HARVESTER DR STE 300
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-5965
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1801 W TAYLOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4795
Practice Address - Country:US
Practice Address - Phone:312-996-3631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015461363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDOH38DBOtherCAREFIRST MARYLAND
DC020353D28OtherINDIVIDUAL MEDICARE NUMBU
DC3696OtherCAREFIRST DC
MD648871400Medicaid
MD543MP075OtherMEDICARE INDIVIDUAL PROV#
MDOH38DBOtherCAREFIRST MARYLAND
MD648871400Medicaid