Provider Demographics
NPI:1003919382
Name:TERHARK, MELISSA (CRNA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:TERHARK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2814 E 2525TH RD
Mailing Address - Street 2:
Mailing Address - City:MARSEILLES
Mailing Address - State:IL
Mailing Address - Zip Code:61341-9570
Mailing Address - Country:US
Mailing Address - Phone:309-453-9350
Mailing Address - Fax:309-692-2538
Practice Address - Street 1:8600 NORTH STATE ROUTE 91
Practice Address - Street 2:SUITE #250
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615
Practice Address - Country:US
Practice Address - Phone:309-692-5394
Practice Address - Fax:309-692-2538
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041253749367500000X
IL209.005184367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK23027Medicare ID - Type Unspecified