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General NPI Number Information
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NPI Number | 1396453346
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Entity Type | Individual
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Provider Name | MELINDA SUE HICKEY MSN, AGNP-C, CWON
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Gender | Female
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Dates
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Enumeration Date | 11/08/2022
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Last Update Date | 05/13/2025
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Provider Practice Location Address
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Address Line | 221 NE GLEN OAK AVE
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City | PEORIA
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State | IL
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Zip | 61636-0001
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Country | US
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Telephone | 309-678-2218
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Fax |
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Provider Business Mailing Address
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Address Line | 355 S BRIDGE ST
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City | BANNER
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State | IL
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Zip | 61520-9307
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Country | US
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Telephone | 309-650-0615
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 209027429
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number | AG09220121
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License Number State | IL
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