Healthcare Provider Details

I. General information

NPI: 1235853904
Provider Name (Legal Business Name): MELISSA CANTU FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2022
Last Update Date: 09/27/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4318 N CALIFORNIA AVE UNIT 401
CHICAGO IL
60618-1880
US

IV. Provider business mailing address

4318 N CALIFORNIA AVE UNIT 401
CHICAGO IL
60618-1880
US

V. Phone/Fax

Practice location:
  • Phone: 910-322-8485
  • Fax:
Mailing address:
  • Phone: 910-322-8485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.026069
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.526617
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: