Basic Information
| Provider Information | |||||||||
| NPI: | 1295124766 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAHOLKE | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | APN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EARNEST | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | K. | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1005 HEALTH CENTER DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619384653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173423400 | ||||||||
| FaxNumber: | 2172582216 | ||||||||
| Practice Location | |||||||||
| Address1: | 1303 W EVERGREEN AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624011638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173472332 | ||||||||
| FaxNumber: | 2172472313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2015 | ||||||||
| LastUpdateDate: | 07/29/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 277000346 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.