Basic Information
| Provider Information | |||||||||
| NPI: | 1184191363 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | JEANETTE | ||||||||
| MiddleName: | ILENE | ||||||||
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| Credential: | NURSE ANESTHETIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 809 APACHE DR | ||||||||
| Address2: | |||||||||
| City: | SIKESTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638014015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737033298 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2 GOOD SAMARITAN WAY STE 205 | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628642476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6188993869 | ||||||||
| FaxNumber: | 6188993558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2018 | ||||||||
| LastUpdateDate: | 10/25/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 118890 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.