=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033530548
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA KOEHLER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/31/2013
-----------------------------------------------------
Last Update Date | 12/31/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 572 LINCOLN AVE SUITE #3
-----------------------------------------------------
City | WINNETKA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60093-2308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-501-4040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2323 CENTRAL ST APT 3W
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60201-5736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-826-0903
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | 209.011071
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 041.415962
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------