{
"Npi": {
"NPI": "1396453346",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "N",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "HICKEY",
"FirstName": "MELINDA",
"MiddleName": "SUE",
"NamePrefix": null,
"NameSuffix": null,
"Credential": "MSN, AGNP-C, CWON",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": "GANGLOFF",
"OtherFirstName": "MELINDA",
"OtherMiddleName": "SUE",
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": "5",
"FirstLineMailingAddress": "355 S BRIDGE ST",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "BANNER",
"MailingAddressStateName": "IL",
"MailingAddressPostalCode": "61520-9307",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "309-650-0615",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "221 NE GLEN OAK AVE",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "PEORIA",
"PracticeLocationAddressStateName": "IL",
"PracticeLocationAddressPostalCode": "61636-0001",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "309-678-2218",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "11/08/2022",
"LastUpdateDate": "05/13/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "363LG0600X",
"TaxonomyName": "Gerontology Nurse Practitioner",
"LicenseNumber": "209027429",
"LicenseNumberStateCode": "IL",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "363LP2300X",
"TaxonomyName": "Primary Care Nurse Practitioner",
"LicenseNumber": "AG09220121",
"LicenseNumberStateCode": "IL",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}