=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457730038
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA ANNE DOUTHIT NP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2015
-----------------------------------------------------
Last Update Date | 12/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3665 PARK PL W STE 300
-----------------------------------------------------
City | MISHAWAKA
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-448-3627
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 901 MCCLINTOCK DR STE 202
-----------------------------------------------------
City | BURR RIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60527-0872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-448-3627
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | RN218345
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 71008133A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------