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General NPI Number Information
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NPI Number | 1912294083
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Entity Type | Individual
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Provider Name | MELISSA THEODORE NP
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Gender | Female
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Dates
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Enumeration Date | 07/08/2011
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Last Update Date | 01/14/2026
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Provider Practice Location Address
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Address Line | 2650 RIDGE AVE
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City | EVANSTON
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State | IL
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Zip | 60201-1700
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Country | US
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Telephone | 847-570-1010
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Fax | 847-733-5108
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Provider Business Mailing Address
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Address Line | 2650 RIDGE AVE STE 1223
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City | EVANSTON
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State | IL
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Zip | 60201-1700
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Country | US
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Telephone | 847-570-2040
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Fax | 847-733-5315
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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 | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | 277000045
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 277000045
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License Number State | IL
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