Basic Information
| Provider Information | |||||||||
| NPI: | 1215144951 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLINGSON | ||||||||
| FirstName: | ANTOINETTE | ||||||||
| MiddleName: | GAIL | ||||||||
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| Credential: | C.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2400 N ROCKTON AVE | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611033655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159715000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2400 N ROCKTON AVE | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611033655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159715810 | ||||||||
| FaxNumber: | 8159719627 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2007 | ||||||||
| LastUpdateDate: | 02/19/2008 | ||||||||
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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 | 363LF0000X | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.