Healthcare Provider Details

I. General information

NPI: 1750833356
Provider Name (Legal Business Name): MELISSA MARIE GLASS APRN-FPA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MELISSA M GLASS APRN-FPA

II. Dates (important events)

Enumeration Date: 10/29/2016
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S 13TH ST
PEKIN IL
61554-4936
US

IV. Provider business mailing address

2124 HIGHWOOD AVE
PEKIN IL
61554-6328
US

V. Phone/Fax

Practice location:
  • Phone: 309-347-1151
  • Fax: 309-347-6016
Mailing address:
  • Phone: 309-275-6363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number277.001921
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number277.001920
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: