Provider Demographics
NPI:1104653997
Name:ELLIS, MADELINE (DNP, AG-ACNP-BC)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DNP, AG-ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N WESTMORELAND RD # LEVEL1
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1658
Mailing Address - Country:US
Mailing Address - Phone:312-695-1800
Mailing Address - Fax:847-535-7151
Practice Address - Street 1:1000 N WESTMORELAND RD # LEVEL1
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1658
Practice Address - Country:US
Practice Address - Phone:312-695-1800
Practice Address - Fax:847-535-7151
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-17
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209030895363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care