Provider Demographics
NPI:1982985180
Name:CLARKE, ELIZABETH ELLEN (RN)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ELLEN
Last Name:CLARKE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 BUSSE RD
Mailing Address - Street 2:
Mailing Address - City:MARENGO
Mailing Address - State:IL
Mailing Address - Zip Code:60152-8040
Mailing Address - Country:US
Mailing Address - Phone:815-943-0253
Mailing Address - Fax:
Practice Address - Street 1:8420 W BRYN MAWR AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-3479
Practice Address - Country:US
Practice Address - Phone:773-355-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-31
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.220408163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse