Healthcare Provider Details

I. General information

NPI: 1063165017
Provider Name (Legal Business Name): MELISSA CONIARIS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2022
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7343 LAKE ST
RIVER FOREST IL
60305-2206
US

IV. Provider business mailing address

40 75TH ST
WILLOWBROOK IL
60527-2325
US

V. Phone/Fax

Practice location:
  • Phone: 708-231-8908
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.024945
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number041368468
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: