Provider Demographics
NPI:1952705006
Name:EARLS, ELLAWEASE
Entity Type:Individual
Prefix:
First Name:ELLAWEASE
Middle Name:
Last Name:EARLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8801 S CONSTANCE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-2955
Mailing Address - Country:US
Mailing Address - Phone:773-206-2468
Mailing Address - Fax:773-382-0333
Practice Address - Street 1:8801 S CONSTANCE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-2955
Practice Address - Country:US
Practice Address - Phone:773-206-2468
Practice Address - Fax:773-382-0333
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor