Healthcare Provider Details

I. General information

NPI: 1306219209
Provider Name (Legal Business Name): MELISSA STROM APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2015
Last Update Date: 12/26/2021
Certification Date: 12/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 BUCKLIN ST
LA SALLE IL
61301-2389
US

IV. Provider business mailing address

1230 7TH AVE
LONGVIEW WA
98632-3166
US

V. Phone/Fax

Practice location:
  • Phone: 815-220-7170
  • Fax:
Mailing address:
  • Phone: 360-636-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: