Healthcare Provider Details

I. General information

NPI: 1972988418
Provider Name (Legal Business Name): JOSEPH MELLENS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2015
Last Update Date: 11/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 MADISON ST
JOLIET IL
60435-8200
US

IV. Provider business mailing address

817 W WASHINGTON BLVD UNIT 304
CHICAGO IL
60607-2390
US

V. Phone/Fax

Practice location:
  • Phone: 815-725-7133
  • Fax:
Mailing address:
  • Phone: 312-928-9089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209013598
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.383038
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: