Healthcare Provider Details

I. General information

NPI: 1619438892
Provider Name (Legal Business Name): MELISSA PRYER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2019
Last Update Date: 12/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 BROADWAY, SUITE 1
MT. VERNON IL
62864
US

IV. Provider business mailing address

210 S WASHINGTON ST
MC LEANSBORO IL
62859-1139
US

V. Phone/Fax

Practice location:
  • Phone: 618-927-0461
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.006184
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: