Basic Information
| Provider Information | |||||||||
| NPI: | 1528079803 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLISON | ||||||||
| FirstName: | LARA | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2007 95TH ST | ||||||||
| Address2: | STE 105 | ||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605637802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306466920 | ||||||||
| FaxNumber: | 6306466925 | ||||||||
| Practice Location | |||||||||
| Address1: | 2007 95TH STREET | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605637802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306466920 | ||||||||
| FaxNumber: | 6306466925 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 03/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036114549 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036114549 1 | 05 | IL | MEDICAID |