MEDICARE: MELISSA THEODORE NP

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	363LA2200X	Adult Health Nurse Practitioner	277000045	IL
2	363L00000X	Nurse Practitioner	277000045	IL

General Provider Information

NPI Number	:	1912294083
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA THEODORE NP

Provider Business Mailing Address
First Line	:	2650 RIDGE AVE STE 1223
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60201-1700
Country	:	US
Telephone Number	:	847-570-2040
Fax Number	:	847-733-5315

Provider Business Practice Location Address
First Line	:	2650 RIDGE AVE
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60201-1700
Country	:	US
Telephone Number	:	847-570-1010
Fax Number	:	847-733-5108

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

Provider Enumeration Date	:	07/08/2011
Last Update Date	:	01/14/2026

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