Healthcare Provider Details

I. General information

NPI: 1114763737
Provider Name (Legal Business Name): MELISSA M THEOBALD FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2024
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3626 N SHERIDAN RD
PEORIA IL
61604-1401
US

IV. Provider business mailing address

19014 N DAILY RD
PRINCEVILLE IL
61559-9312
US

V. Phone/Fax

Practice location:
  • Phone: 309-308-5100
  • Fax:
Mailing address:
  • Phone: 309-231-2050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041362793
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209030474
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: