Healthcare Provider Details

I. General information

NPI: 1760791917
Provider Name (Legal Business Name): MELISSA J RICHARDSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2010
Last Update Date: 09/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 N CLARK ST
CHICAGO IL
60610-2702
US

IV. Provider business mailing address

415 HOWARD ST APT 816
EVANSTON IL
60202-4007
US

V. Phone/Fax

Practice location:
  • Phone: 866-389-2727
  • Fax: 401-652-9787
Mailing address:
  • Phone: 815-298-7382
  • Fax: 401-652-9787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209008300
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: