Basic Information
| Provider Information | |||||||||
| NPI: | 1811965973 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FELLINGHAM | ||||||||
| FirstName: | SHARON | ||||||||
| MiddleName: | DENISE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 767 PARK AVE WEST SUITE #350 | ||||||||
| Address2: | PARK AVE. ASSOCIATES IN INTERNAL MEDICINE | ||||||||
| City: | HIGHLAND PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479264445 | ||||||||
| FaxNumber: | 8476810994 | ||||||||
| Practice Location | |||||||||
| Address1: | 767 PARK AVE WEST SUITE #350 | ||||||||
| Address2: | PARK AVE. ASSOCIATES IN INTERNAL MEDICINE | ||||||||
| City: | HIGHLAND PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7735497757 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 05/06/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085001834 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 085001834 | 01 | IL | LICENSE | OTHER |