Healthcare Provider Details

I. General information

NPI: 1467575092
Provider Name (Legal Business Name): MELISSA J. DYE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 10/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2805 N KNOXVILLE AVE
PEORIA IL
61604-2869
US

IV. Provider business mailing address

2805 N KNOXVILLE AVE
PEORIA IL
61604-2869
US

V. Phone/Fax

Practice location:
  • Phone: 309-624-9400
  • Fax: 309-624-2280
Mailing address:
  • Phone: 309-624-9400
  • Fax: 309-624-2280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number209-006545
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code364SM0705X
TaxonomyMedical-Surgical Clinical Nurse Specialist
License Number209-006545
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: