MEDICARE: MELISSA KOEHLER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	041.415962	IL
2	363LP0200X	Pediatric Nurse Practitioner	209.011071	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	209.011071	OTHER	IL	APN LICENSE
2	041.415962	OTHER	IL	RN LICENSE

General Provider Information

NPI Number	:	1033530548
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA KOEHLER

Provider Business Mailing Address
First Line	:	2323 CENTRAL ST
Second Line	:	APT 3W
City	:	EVANSTON
State	:	IL
Zip	:	60201-5736
Country	:	US
Telephone Number	:	847-826-0903
Fax Number	:

Provider Business Practice Location Address
First Line	:	572 LINCOLN AVE
Second Line	:	SUITE #3
City	:	WINNETKA
State	:	IL
Zip	:	60093-2308
Country	:	US
Telephone Number	:	847-501-4040
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/31/2013
Last Update Date	:	12/31/2013

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Directions to “ MELISSA KOEHLER ” Practice Location

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