Healthcare Provider Details

I. General information

NPI: 1235765249
Provider Name (Legal Business Name): MELINDA SUE DIAL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2020
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 W CHESTNUT ST
BLOOMINGTON IL
61701-2814
US

IV. Provider business mailing address

419 S WALNUT ST
WAPELLA IL
61777-2501
US

V. Phone/Fax

Practice location:
  • Phone: 618-877-4420
  • Fax:
Mailing address:
  • Phone: 217-871-8050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209020879
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: