MEDICARE: MELISSA WHITMAN CRNA

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	041-229441	IL
2	367500000X	Certified Registered Nurse Anesthetist	209-001967	IL

General Provider Information

NPI Number	:	1831242197
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA WHITMAN CRNA

Provider Business Mailing Address
First Line	:	19627 S LA GRANGE RD
Second Line	:
City	:	MOKENA
State	:	IL
Zip	:	60448-9360
Country	:	US
Telephone Number	:	708-326-1632
Fax Number	:	708-326-1672

Provider Business Practice Location Address
First Line	:	19627 S LA GRANGE RD
Second Line	:
City	:	MOKENA
State	:	IL
Zip	:	60448-9360
Country	:	US
Telephone Number	:	708-326-1632
Fax Number	:	708-326-1672

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

Provider Enumeration Date	:	01/19/2007
Last Update Date	:	03/12/2015

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