Individual
MRS. ELLY JO FENNELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
RN, CNP
Contact information
Practice address
720 ESKENAZI AVE, INDIANAPOLIS, IN 46202-5187
(317) 880-7666
Mailing address
PO BOX 637764, CINCINNATI, OH 45263-7764
(317) 880-3939
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
041-280081
IL
363L00000X
Nurse Practitioner
209.008173
IL
363LA2200X
Adult Health Nurse Practitioner
209.008173
IL
363LA2200X
Adult Health Nurse Practitioner
370911138
IL
364S00000X
Clinical Nurse Specialist
Primary
71009460A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036102163
—
IL
01
—
041-280081
RN LICENSE
IL
01
—
209.008173
CNP LICENSE
IL
Enumeration date
05/04/2010
Last updated
09/16/2025
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