Provider Demographics
NPI:1265954069
Name:WILLIAMS, ELISSA CATHERINE (APN)
Entity type:Individual
Prefix:MRS
First Name:ELISSA
Middle Name:CATHERINE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:MS
Other - First Name:ELISSA
Other - Middle Name:CATHERINE
Other - Last Name:MIKOL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:603 WASHINGTON BLVD APT 2
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-3980
Mailing Address - Country:US
Mailing Address - Phone:708-738-4630
Mailing Address - Fax:
Practice Address - Street 1:225 E CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2991
Practice Address - Country:US
Practice Address - Phone:708-738-4630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-13
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.016088363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner