Healthcare Provider Details

I. General information

NPI: 1003232489
Provider Name (Legal Business Name): MELISSA G KULP MS, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA G LANE FPA APRN

II. Dates (important events)

Enumeration Date: 03/10/2014
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 E COUNTY RD E ANNEX
JERSEYVILLE IL
62052-3125
US

IV. Provider business mailing address

390 MAPLE SUMMIT RD
JERSEYVILLE IL
62052-2000
US

V. Phone/Fax

Practice location:
  • Phone: 618-498-8467
  • Fax: 618-639-2017
Mailing address:
  • Phone: 618-498-7518
  • Fax: 618-498-3052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number277001416
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: