Healthcare Provider Details

I. General information

NPI: 1972182962
Provider Name (Legal Business Name): MELINDA ANNETTE BIRDWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2021
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 W EXCHANGE ST
FREEPORT IL
61032-4008
US

IV. Provider business mailing address

PO BOX 813
FREEPORT IL
61032-0813
US

V. Phone/Fax

Practice location:
  • Phone: 815-599-7300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SC1501X
TaxonomyCommunity Health/Public Health Clinical Nurse Specialist
License Number041429531
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: