Healthcare Provider Details

I. General information

NPI: 1003919382
Provider Name (Legal Business Name): MELISSA TERHARK C.R.N.A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 11/03/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 NORTH STATE ROUTE 91 SUITE #250
PEORIA IL
61615
US

IV. Provider business mailing address

2814 E 2525TH RD
MARSEILLES IL
61341-9570
US

V. Phone/Fax

Practice location:
  • Phone: 309-692-5394
  • Fax: 309-692-2538
Mailing address:
  • Phone: 309-453-9350
  • Fax: 309-692-2538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number041253749
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209.005184
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: