Healthcare Provider Details

I. General information

NPI: 1659682359
Provider Name (Legal Business Name): THERESE MARIE MELANIPHY APN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2010
Last Update Date: 09/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4647 W. LINCOLN HIGHWAY
MATTESON IL
60443-2319
US

IV. Provider business mailing address

27702 NETWORK PL
CHICAGO IL
60673-1277
US

V. Phone/Fax

Practice location:
  • Phone: 708-747-7720
  • Fax:
Mailing address:
  • Phone: 708-862-7674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209008017
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: