Healthcare Provider Details

I. General information

NPI: 1124875414
Provider Name (Legal Business Name): MELISSA NICOLE TEYIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2024
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2833 S GRAND AVE E
SPRINGFIELD IL
62703-2175
US

IV. Provider business mailing address

2833 S GRAND AVE E
SPRINGFIELD IL
62703-2175
US

V. Phone/Fax

Practice location:
  • Phone: 217-535-3100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.029656
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: