Basic Information
| Provider Information | |||||||||
| NPI: | 1114245958 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FENNELL | ||||||||
| FirstName: | ELLY | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN, CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WEAR | ||||||||
| OtherFirstName: | ELLY | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3900 ST FRANCIS WAY STE 205 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479054939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654282500 | ||||||||
| FaxNumber: | 7654282505 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 ESKENAZI AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462025187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178807666 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2010 | ||||||||
| LastUpdateDate: | 11/18/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209.008173 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | 209.008173 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | 370911138 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 364S00000X | 71009460A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | 163W00000X | 041-280081 | IL | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 041-280081 | 01 | IL | RN LICENSE | OTHER | 036102163 | 05 | IL | MEDICAID | 209.008173 | 01 | IL | CNP LICENSE | OTHER |