Provider Demographics
NPI:1003232489
Name:KULP, MELISSA G (MS, FNP-BC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:G
Last Name:KULP
Suffix:
Gender:F
Credentials:MS, FNP-BC
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:G
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FPA APRN
Mailing Address - Street 1:390 MAPLE SUMMIT RD
Mailing Address - Street 2:
Mailing Address - City:JERSEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62052-2000
Mailing Address - Country:US
Mailing Address - Phone:618-498-8467
Mailing Address - Fax:618-639-2017
Practice Address - Street 1:220 E COUNTY RD
Practice Address - Street 2:E ANNEX
Practice Address - City:JERSEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62052-3125
Practice Address - Country:US
Practice Address - Phone:618-498-8467
Practice Address - Fax:618-639-2017
Is Sole Proprietor?:No
Enumeration Date:2014-03-10
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.011300363LF0000X
IL277001416363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL277001416OtherILLINOIS DEPARTMENT OF PROFESSIONAL REGULATION