Basic Information
| Provider Information | |||||||||
| NPI: | 1750833356 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLASS | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN-FPA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GLASS | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | APRN-FPA | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2124 HIGHWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | PEKIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615546328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3092756363 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 600 S 13TH ST | ||||||||
| Address2: | |||||||||
| City: | PEKIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615544936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3093471151 | ||||||||
| FaxNumber: | 3093476016 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2016 | ||||||||
| LastUpdateDate: | 05/04/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SA2200X | 277.001921 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Adult Health | 363LF0000X | 277.001920 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.